We have seen a lot of RAC audit activity in Jurisdiction C from Connolly Healthcare requiring CPAP suppliers to provide copies of qualifying sleep test results. Early trends attribute audited claims to patients with PAP equipment where Medicare did not originally pay for the sleep study (perhaps the patient had prior coverage through a commercial plan). 

You may remember a previous audit conducted by the Jurisdiction D RAC in early 2011 for Medicare covered sleep tests, where the RAC misinterpreted the language in the PAP LCD to mean that Medicare had to actually pay for the patient’s test. This has never been the case and the audit was proven to be invalid. The RAC ultimately issued refunds to audited suppliers and the LCD language was revised to clarify that sleep tests only need to show the patient “meets the Medicare coverage criteria in effect for the date of service of the claim,” not actually be paid for by Medicare.

It should be noted that the audits currently ongoing in Jurisdiction C are entirely different from the 2011 Jurisdiction D audit, and we do not expect to see a retraction. In this case, the Jurisdiction C RAC is only requesting that suppliers provide a copy of the patient’s qualifying test results to prove that a sleep test took place and has NOTHING to do with whether Medicare actually paid for the test.

The ongoing audits are semi-automated, meaning they are a cross between an automated and complex review. As with an automated review, claims are targeted for semi-automated review based on a software driven process, which identifies aberrant billing patterns (billing trends outside the norm). However, unlike automated reviews, there is only a suspicion that the supplier billed incorrectly. Since the RAC is not 100% sure an error has occurred, payment may not be automatically recouped, as would be done under a true automated review (i.e. payments after a date of death).  This requires the RAC to send the supplier a letter requesting more information, as is done with complex reviews.

For the most part, semi-automated reviews are glorified complex reviews but with none of the protections. The supplier must send in additional information before the final determination is made (lack of response defaults to an overpayment and denial). However, unlike complex reviews, there is currently no limit on the number of semi-automated reviews a RAC may perform. Documentation request limits for complex reviews prohibit RACs from requesting  records for more than 10% of your annual billing volume per 45-days, with a max cap of 250 records/45-days.

When we called Connolly Healthcare  (the Region C RAC) to ask why there is no limit on record requests for semi-automated reviews, we were told that it is because a response to an “informational” request from a semi-automated review is optional, whereas response to a “documentation” request from a complex review is mandatory. Although if you ask us, there is nothing optional about responding to a semi-automated review if you want your claim to be paid.

You will know if you are selected for a semi-automated review by looking at the top of the review letter. If the bolded header says “Informational Letter” and the subject of the letter mentions “semi-automated review results are attached”, then the review is semi-automated, and you will have 45-days to submit information to support your claim. If you do not respond within the given time frame, the claim will be sent to your MAC for adjustment and a demand letter will be issued.

In the case of Jurisdiction C’s semi-automated CPAP reviews, all that is currently being requested is the sleep test itself. Suppliers may stave off recoupments by submitting a copy of the patient’s qualifying sleep test within 45-days of receiving the information request from the RAC. To be successful, the test must show a qualifying AHI or RDI (as defined in the PAP LCD), and that the patient was diagnosed with OSA.

A new pilot program, scheduled to begin in September 2011, will allow providers and suppliers to respond to documentation requests from most audit contractors electronically. Per CMS, the primary goal of Medicare’s Electronic Submission of Medical Documentation (esMD) pilot project is to reduce costs and cycle time by minimizing and eventually eliminating the mailing of paper documentation to medical review contractors.

The esMD program will be implemented in two phases. Beginning in September of this year, suppliers will have the option to respond to documentation request letters electronically. By 2012, CMS will expand esMD to allow review contractors to also send electronic documentation requests, rather than mailing paper letters.

Participation in the esMD program is completely voluntary. Physicians, hospitals and suppliers who wish to participate will need to obtain access to a special internet gateway, known as a CONNECT-compatible gateway, that meets the security standards established by the Nationwide Health Information Network (NHIN). Much like the network service vendors charged with providing connectivity to the CEDI gateway, suppliers will need to go through an authorized Health Information Handler (HIH) to obtain access to the esMD system. A total of 27 HIH’s will ultimately offer access to a CONNECT-compatible gateway; however, only the following 5 are expected to be ready to handle transmissions by September 2011: 

• HealthPort (http://www.healthport.com/)
• IVANS (http://www.ivans.com/)
• MRO (http://www.mrocorp.com/)
• NaviNet (http://www.navinet.net/)
• RISARC (http://www.risarc.com/)

Suppliers should take the following into consideration when deciding whether to participate in esMD:

1. Just like with the CEDI network vendors, the HIHs will likely charge suppliers a fee to submit documentation through their gateways. Fees are set independently by each HIH and are not regulated by CMS, so be sure to shop around.
2. The esMD system will only accept documents in a portable document format (PDF). Paper documents will need to be scanned and converted into PDF files before being transmitted. If you have an electronic health record system or program that is able to export information in PDF format, such as Adobe Acrobat, this should not be an issue. Also, some HIHs may also offer scanning and conversion services in addition to their esMD services.
3. Not all audit contractors are accepting electronic submissions at this time. While all DME MACs are expected to eventually participate, not all RAC and ZPIC contractors have jumped on board. Suppliers who do not wish to participate in esMD or who are submitting responses to non-participating medical review contractors may continue to mail or fax documentation for review.

Medical review contractors planning to participate in the esMD program and accept electronic submissions include:

Beginning September 2011:

• The CERT Contractor
• RAC A (DCS)
• RAC B (CGI)
• DME MAC A (NHIC)
• DME MAC D (NAS)

Beginning November 2011:

• RAC D (HelathDataInsights)
• DME MAC B (NGS)
• ZPIC for  Zones 1 and 7 (SafeGaurd Services)

Beginning January 2012:

• DME MAC C (CGS)

Although the Jurisdiction C RAC (Connolly Healthcare) has not confirmed participation in esMD, CMS expects the RAC to begin accepting electronic transactions within the next 12 months. At this time, there is no word on whether the remaining ZPIC contractors will participate.

For more information, including a complete list of providers who plan to offer esMD gateway access, visit: http://www.cms.gov/esMD and http://www.qssinc.com/esmd.

If you are among the suppliers who have received massive recoupment notices for infusion supplies (HCPCS A4221) in Jurisdiction C, don’t panic. Recently, the Jurisdiction C RAC, Connolly Healthcare, implemented an automated, post-pay review of claims billed for excessive units of infusion supplies. Unfortunately, Connolly reversed the editing logic used to review claims so that any infusion supplies billed in excess of Medicare’s allowable were considered appropriate, and all supplies billed within Medicare’s allowable were deemed overpayments.

To put it into perspective, Medicare allows 1 unit to be billed for a week’s worth of infusion supplies. (Note: Suppliers should not bill quantities per infusion set, although many patients receive 2-4 sets per week; the code is billed per WEEK not per set). Suppliers who routinely billed for 15 units of A4221 every three months (2 over the allowable) were receiving notices that payment for all but 2 units of service would be recouped.

With the collaboration of both the Jurisdiction C RAC and DME MAC, DME consultant Andrea Stark received assurances that claims affected by the flawed editing logic will be automatically readjusted in a timely fashion to prevent offsets. Suppliers do NOT need to submit appeals at this time and will receive updated AR letters once all inappropriate recoupments have been voided.