RAC prepayment audits were originally scheduled to start shortly after January 1, 2012, but have been pushed back until sometime during the summer of 2012. CMS has made it clear the RAC prepayment reviews are in addition to all current claim review processes that are already in place. CMS is looking for these audits to prevent improper payments, so that there will be a decreased need for post payment audits. This is a demonstration project which means that based upon the success / failure of the demonstration this may or may not become a permanent program.
This demonstration will be held in California, Florida, Illinois, Louisiana, Michigan, New York and Texas where there are existing HEAT teams (Health Care Fraud Prevention and Enforcement Action Team) and four states with high volumes of short stays Missouri, North Carolina, Ohio and Pennsylvania. CMS has established a goal of $50 billion for this prepayment review demonstration.
CMS has stated that this demonstration will allow the evaluation of, “whether Recovery Auditors can have an impact on the amount of improper payments that can be prevented through prepayment review without requiring additional MIP funding. The demonstration would also evaluate if the increased amount of prepayment review can have a significant impact on lowering the error rate and lowering the risk of fraudulent occurrences.”
For the purposes of the demonstration, RAC prepayment audits will be focusing on the inpatient environment and the RACS are initially charged with looking at:
The first group of DRGs that will be subject to prepayment review include the following:
MS-DRG 312, syncope and collapse
MS-DRG 069, transient ischemia (TIA)
MS-DRG 377, gastrointestinal hemorrhage with Major Complicating Condition
MS-DRG 378, gastrointestinal hemorrhage with Complicating Condition
MS-DRG 379, gastrointestinal hemorrhage without a Complicating Condition or Major Complicating Condition
MS-DRG 637, diabetes with Major Complicating Condition
MS-DRG 638, diabetes with Complicating Condition
MS-DRG 639, diabetes without a Complicating Condition or Major Complicating Condition
For more information visit http://journal.ahima.org/2012/08/01/preparing-for-rac-prepayment-reviews/