Recovery Audit Contractors (RACs) now employ automated claims reviews and
complex claims reviews with the goal of obtaining a refund of fees that physical
therapists have received for services rendered. A new form of audit has
been introduced to assist the RAC bounty hunter goal of obtaining a refund from
providers (they are reimbursed when they obtain a refund). The new method
is known as overpayment identification: “Semi-automated” claims review.
Semi-automated review is slightly different than the automated and complex
methods of overpayment identification used in the RAC method. It is
essentially a hybrid of the automated and complex reviews. The changes
divide this new review process into two parts.
- The first part of the two-part review process involves an automated review of
claims data to identify billings that are associated with a high suspicion of
improper payment. The automated RAC review occurs when a determination is made
at the computerized system level without a person. Software reviews are often
referred to as “Data mining,” where the software to process large numbers of
claims combs the data. It is essentially unchanged from prior RAC reviews. The
minor difference from the regular automated RAC is claims that are identified as
only containing possible errors, rather than assumed errors, are identified.
- The second part has a notification letter sent to the therapist explaining the
potential billing error. The PT is given 45 days to submit documentation to
support the original billing(45 days is also given to providers to submit
documentation for a claim that has been selected for complex review).
“Semi-automated” reviews will lead to additional burdens for physical
therapists. It is no secret that automated reviews can result into a
complex review. The semi-automated review has established the process that
emphasizes the risks of automated review, making it easier for the RACs to
request records for review! . The RACs can now scan unknown numbers of
records for issues, ‘mining’ for unlimited vulnerabilities.
I know the overwhelming majority of therapist are unaware of or ignoring the
impact of the documentation tsunami that approaches. I know because I
speak with MediGraph
subscribers regularly. I also speak with therapists that are
interested in becoming MediGraph
subscribers, and most of them are clueless. Increasingly, new callers are
aware of what approaches, which is their reason for seeking electronic
For subscribers, I understand that my good intentions are becoming a bore.
I realize that I am the bearer of bad news that many would prefer to ignore,
pretending that that are immune. If you are already a subscriber, it
should be apparent that there are no ulterior motives to my posts that implore
you to use MediGraph to its
MediGraph does not gain any income when you use the tools that we have
provided. Please document need, proof, meaningful intervention, and use
objective tools in MediGraph
to accomplish these tasks. All these tools required to satisfy the
Medicare bounty hunters and bean counters are at your disposal. Start
using these tools today. The RACs are using their software to the fullest
capacity to snag you. Use
MediGraph to beat them at their own game.
Tom Kane, PT