Providers of Group 3 air-fluidized beds in Jurisdiction C started getting bombarded with automated recoupments from Connolly Healthcare in December, and could not figure out why the claims were being recouped without development.
When researching a RAC audit, the first step is to visit the RAC website and locate the CMS approved audit issues. We discovered that the websites post a shortened version of the audit issues, and with automated reviews providers do not get development letters that contain the full version of the audit issue direct from the RAC. Therefore, they do not get an opportunity to view the full description of the audit logic. Attempts to figure out the true root of the audit logic were elusive until a dialogue began with senior RAC officials.
Upon viewing the detailed rationale, we discovered that the claims were being recouped based on a provision in the LCD that requires the USE of a Group 2 support surface 30 days prior to initiation of therapy with a Group 3 bed. We dug in a little deeper and researched claims from the audited sample and found that most fell into two categories: 1) either the patient had a Group 2 in their history that had capped out and was no longer actively billing, or 2) the patient obtained a Group 2 from another insurer. In all cases, the patients had used a Group 2 support surface prior to the Group 3, but the problem was that none of the claims had a PAYMENT for a Group 2 immediately before the first service date for the Group 3.
Connolly was receptive to meeting with us to discuss our concerns that the logic structure was targeting too broad a sample. There are a number of logical reasons that there will be no payment history immediately preceding the Group 3 delivery. In our dialogue with Connolly, we pointed out that many patients will be on Group 2 therapy for extended periods of time prior to initiation of Group 3 therapy. The Group 2 products are capped rentals and they convert to purchases after 13 months of rental. Connolly officials actively listened to our concerns and agreed the logic should be modified. As a result, the audit was converted from a fully automated review to a semi-automated review. Connolly additionally modified the logic so that if they find any history of a Group 2 in the data they have available, the claim will NOT be targeted for recoupment or further review. However, when these provisions cannot be established, the claims will be developed for a complex review/response from the provider to prove the patient had used the Group 2 prior to the Group 3. This is a HUGE win for providers in this product space!
We are very pleased to report that the logic has already been corrected as of our March conversation and will not affect claims going forward. However, any appeals in the works for previously targeted claims will have to be resolved through normal channels. Separate from this audit issue, Connolly has another complex review that is targeting Group 3 claims for development and this audit will require providers to establish documentation that fully complies with all aspects of the LCD to support medical necessity. When claims are developed for complex review, providers are given 45 days to send in a response to the request.
Audits aren’t going anywhere, and in the course of an increasing number of audits, mistakes will be made by contractors and providers alike. The key take-away here is that it is possible to establish a reasonable dialogue with contractors. These dialogues can lead to a meaningful modification of audits with unintended consequences.