The top problem uncovered by the Medicare Recovery Audit Contractor (RAC) for Texas’ Region C involves showing medical necessity for cardiovascular procedures, according the Centers for Medicare & Medicaid Services (CMS).

A quarterly report (PDF) for October-December 2012 says: “Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation for patients undergoing cardiovascular procedures needs to be complete and support all services provided in the setting billed.”

RAC auditor Connolly, Inc. audits claims for a long list of CMS-approved issues. In this list, those applicable to Texas are the ones with a States column notation of “Novitas Region C,” “Region C,” “Texas,” or “TrailBlazer Region C.” For the quarter referenced above, Connolly collected $244 million in overpayments from Region C.

Need to Appeal? 

CMS recently released a four-page brochure (PDF) that summarizes the recovery audit process, with a flow chart and links for more information. If you receive an overpayment determination letter from Connolly, review your options. If you decide to appeal, go to Novitas’ online Appeals Center to find the forms, process, timeframes, and requirements.

Your best lines of defense against a RAC audit are knowledge of coverage policies and of regular self-audits. Be sure to follow Medicare guidelines, national coverage determinations, and Novitas JH local coverage determinations when you bill for services. You can learn how to conduct a self-audit, what to do with your findings, and how to obtain buy-in for corrective actions in TMA’s on-demand webinar, Avoiding RAC Audits. Or, contact TMA Practice Consulting at (800) 523-8776 to schedule a Coding and Documentation Review.

Published March 12, 2013 

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