Part B Insider (Multispecialty) Coding Alert

Published on Sat Dec 09, 2006 PDF

RACs still hunting for physician waste in three states

The so-called Medicare -bounty hunters,- which receive payment based on how much money they collect, still have doctors in their sights after they reaped $17.9 in overpayments this year. (See PBI, Vol. 7, No. 42.)

The Recovery Audit Contractors (RACs) have been sending -a large number- of letters to urologists and oncologists in California seeking information about Lupron therapy, according to the Physician Regulatory Issues Team (PRIT) at the Centers for Medicare & Medicaid Services (CMS).

The problem: The letters are vaguely written and confusing, and don't specify which medical records the providers should send in, according to the PRIT's William Rogers. The PRIT has received a copy of the RAC letter and is trying to rewrite it to make it clear exactly which records the RACs require.

The letter -needs to be more specific,- so you won't have to copy and send hundreds of pages of records, says Rogers. Lupron is typically administered in the physician office for prostate cancer, and it's a -big ticket item.- But it's hard to imagine that physicians would administer this medication to patients who didn't really have prostate cancer, says Rogers.

The RACs appear to have solved earlier problems, where they were following up cases that had already been audited by the carriers, says Rogers. They-re also no longer looking back at earlier cases than the time period they should have been handling.

The Dec. 4 meeting of the Practicing Physicians Advisory Council (PPAC) examined the most recent report on the RACs- activities. PPAC also had some questions about whether the newest quality measures added to the physician voluntary reporting project (PVRP) accurately represent the quality of physician services.

Meanwhile, some oncologists have contacted the PRIT because of concerns that Medicare is underpaying for two colony-stimulating factor drugs based on a pricing scheme that only applies if you buy both together. If you try to buy either drug separately, you can't obtain it at the Part B price, the oncologists complain.