February 2009 Newsletter
Preparing for the RAC Program
Looming ominously on the horizon, “Section 302 of the Tax Relief and Health Care Act of 2006 makes the RAC (Recovery Audit Contractors) Program permanent and requires the Secretary [HHS] to expand the program to all 50 states by no later than 2010.” CMS plans to have four RACs in place by 2010, and each RAC will be responsible for identifying overpayment and underpayments in approximately one quarter of the country.
This announcement has brought a mixture of reactions from our clients ranging from panic to indifference, which, for the most part, correlates to the level of confidence in the staff, policies, and practices of each facility.
The Quadax perspective is that Xpeditor and its Tracking provides highly supportable levels of documentation to explain how individual claims are billed—from how the claim was imported initially to who touched it and what was changed before it was released. Following that, the portion of the 837 sent to the payer is made available to each client, allowing them to verify that our conversion and mapping processes maintain the integrity of the data supplied.
However, we strongly encourage a review of two of Xpeditor’s extensively utilized capabilities: Custom Converts and XpressBillers. This review should pay particular attention to automatic changes to procedure and diagnosis codes with a critical eye to the addition of modifiers to resolve edit conflicts.
The Quadax position is that Custom Converts are created at the written request of a client, with the philosophy that the rationale for such a modification of claim data is controlled by the customer. Likewise, an XpressBiller rule that changes data is coded by the end user and includes detailed logging as to the individual responsible for creating it.
In both situations, it is incumbent on you to maintain documentation in the patient’s record to support the various actions.
As an example, the addition of a 59 modifier to satisfy errors raised on claims is a common practice among our clients. In November of 2006, CMS produced a white paper on the use of the 59 modifier as a means to bypass Medicare’s Correct Coding Initiative edits, as well as a detailed document that further defines the code (also noted in the June 2007 issue of Connections). Within it, CMS warns, “Modifier -59 is an important NCCI-associated modifier that is often used incorrectly.”
Use the opportunity of the recent announcements—the final Medicare Administrative Contractors (MACs) and the automatic stay on audits due to the protest—to review your facility’s usage of Custom Converts and XpressBillers to satisfy edit concerns. The EDI Services support team is standing by to help you in whatever capacity we can.