Tag: RAC

WASHINGTON – CMS on Feb. 10 published a change request notifying the DME Medicare Administrative Contractors of the agency’s new national coverage determination for home oxygen therapy.  CMS notes the following changes are effective for claims with dates of service starting Sept. 27, 2021:  expansion of oxygen coverage for acute and chronic conditions;  expansion of coverage for short and long-term need (when hypoxemia exhibited);  the ability of the...

WASHINGTON - CGS, the DME MAC for jurisdictions B and C, will be conducting complex post-pay reviews for surgical dressings and knee orthoses, according to AAHomecare.CGS will be reviewing A6196 and A6212, and L1833 and L1851. The DME MAC is conducting the reviews due to data analysis that showed “significantly above expected amounts.”Surgical dressings and knee orthoses also ranked No. 5 and No. 9, respectively, in total CERT improper payment rates. The reviews will include only claim...

WASHINGTON - Performant, Medicare's RAC, has notified providers by letter that, per authorization from CMS, it will resume certain medical review activities, according to the van Halem Group.The notification says providers have an additional 30 days to submit discussion requests for review for result and initial findings letters dated Feb. 27, 2020, to March 27, 2020. It also advises providers to access the Provider Portal to review any claims pertaining to those dates.Performant most recently posted...

YARMOUTH, Maine - Nearly two years after Performant Recovery announced it would perform an underpayment review for Group 3 power wheelchair options, providers are receiving refund checks, says Andrea Stark.Performant, the DMEPOS RAC, announced in May 2017 it would review wheelchair accessories, including seating systems, and seat and back cushions furnished in conjunction with codes K0848—K0864 for the six-month period of Jan. 1, 2016—June 30, 2016. The review was necessary because CMS...

WASHINGTON - Performant, the national RAC for DME, received approval from CMS on June 14 to audit blood glucose test strips (A4253) nationwide.“The quantity of glucose test strips that are covered depends upon the usual medical needs of the diabetic patient,” reads an announcement on the RAC's website. “Documentation will be reviewed to determine if the utilization guidelines for glucose test strips were met.”The RAC will be reviewing claims that have a “claim paid date”...

WASHINGTON - Reformant Recovery, the National DMEPOS RAC Contractor, has added upper limb orthoses to its approved issues list. Performant will review claims for upper limb orthoses with dates of service within five years of the date of service of a previously paid upper limb orthoses for the same beneficiary. HCPCS codes identified as same, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met… The Jurisdiction B and C councils met recently to...

ATLANTA - Performant Recovery, the national DMEPOS RAC, added pneumatic compression devices to its approved issues list on Jan. 23, the van Halem Group reports. Performant will perform complex reviews to determine if the pneumatic compression device is reasonable and necessary for the patient's condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied. The audit will cover E0651 and E0652 for claims having...

WASHINGTON - Performant Recovery, the new national recovery audit contractor (RAC) for DMEPOS and home health/hospice, has posted seven new reviews on its workload page, according to AAHomecare. They are: complex medical necessity chest wall oscillation devices; complex medical necessity tracheotomy suction catheters, suction pumps, catheters and other related supplies and equipment; automated nebulizers not in accordance with billing requirements; automated DME billed while inpatient; complex review...

CMS has selected five new recovery audit contractors (RACs) and established new rules. RAC audits will undoubtedly resume soon. Performant and Cotiviti were awarded contracts, along with HMS Federal Solutions. A previous RAC auditor, CGI Group, did not bid in the latest round of contracts for RACs. Performant will focus on auditing home medical equipment (HME), home health agency (HHA) and hospice claims. CMS will continue to pay RAC auditors a contingency fee when overpayments are identified....

WASHINGTON - CMS is considering expanding its RAC program for Medicare Advantage, according to a draft scope of work published by the agency.Currently, CMS audits 30 MA contracts per payment year, about 5% of the total number of contracts. Now it is considering increasing the number of contracts that are subject to some type of risk adjustment data validation audit, which validates the accuracy of diagnosis data submitted by MA organizations.“Our ultimate goal is to have all MA contracts subject...