CMS Report Highlights RAC Overpayments, Underpayments

Since October 2009, when Medicare’s fee-for-service Recovery Audit Contractor (RAC) Program went nationwide, health care providers have returned $313.2 million in alleged Medicare overpayments and received $52.6 million in Medicare underpayments, according to a new report from the Centers for Medicare & Medicaid Services (CMS). The report also identifies the top overpayment issues in each of the four RAC regions nationwide.

RACS report the top overpayment issues from fiscal year 2010 through March 2011 involve incorrect coding and improper billing for separating bundled services.

Top Issues Reported by RACs

Region A, Diversified Collection Services: Ventilator support of 96+ hours

“Ventilation hours begin with the intubation of the patient (or time of admittance if the patient is admitted while on mechanical ventilation) and continue until the endotracheal tube is removed, the patient is discharged/transferred, or the ventilation is discontinued after a weaning period. Providers are improperly adding the number of ventilator hours resulting in higher reimbursement.”

Region B, CGI, Inc.: Extensive operating room procedure unrelated to principal diagnosis

“The principal diagnosis and principal procedure codes for an inpatient claim should be related. Errors occur when providers bill an incorrect principal and/or secondary diagnosis that results in an incorrect Medicare Severity Diagnosis-Related Group assignment.”

Region C, Connolly, Inc.: Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provided during an inpatient stay

“Medicare does not make separate payment for DMEPOS when a beneficiary is in a covered inpatient stay.  Suppliers are inappropriately receiving separate DMEPOS payment when the beneficiary is in a covered inpatient stay.”

Region D, HealthDataInsights: DMEPOS provided during an inpatient stay

“Medicare does not make separate payment for DMEPOS when a beneficiary is in a covered inpatient stay. Suppliers are inappropriately receiving separate DMEPOS payment when the beneficiary is in a covered inpatient stay.”

Source: 2011 FFS Newsletter

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