Recovery audit contractors are expected to expand beyond hospitals and spend more time on physicians' billing, shifting from automated to complex reviews of these claims, according to Paul Spencer, a consultant at Fi-Med Management in Wauwautosa, Wis.
Specifically, Mr. Spencer predicts RACs will be scrutinizing place-of-service codes, high-level E&M services and subsequent hospital visits.
RACs will try to match place-of-service codes on physician claims to claims for hospital outpatient services for the same patient on the same day, he says. If there is a match, they will try to recoup the difference between the higher non-facility rate and the facility rate.
Data suggests RACs' work here will be like shooting fish in barrel. Mr. Spencer says a review of 100 non-facility services from 2007, released by CMS in July, found only 10 had the correct place of service. Estimating it overpaid physician claims by $13.8 million, CMS is referring more than 484,000 such claims to RACs and other recovery entities to audit.
Mr. Spencer also expects the complex reviews will look at high level E&M services, under CPT codes 99294 and 99215, and high-level subsequent hospital visits, under CPT codes 99233. Previous studies indicate these codes have very high error rates, he says.
RACs can get an idea of easy targets by reviewing Medicare contractors' service-specific probes, Mr. Spencer says. For example, a service-specific probe by the Medicare contractor for Wisconsin determined a 96 percent error rate for CPT code 99233.
Learn more about Fi-Med Management.
Read more on RACs:
-7 Concerns About the Upcoming Implementation of Medicaid RACs
-CMS Proposes to Let States Implement Medicaid RACs in April
Specifically, Mr. Spencer predicts RACs will be scrutinizing place-of-service codes, high-level E&M services and subsequent hospital visits.
RACs will try to match place-of-service codes on physician claims to claims for hospital outpatient services for the same patient on the same day, he says. If there is a match, they will try to recoup the difference between the higher non-facility rate and the facility rate.
Data suggests RACs' work here will be like shooting fish in barrel. Mr. Spencer says a review of 100 non-facility services from 2007, released by CMS in July, found only 10 had the correct place of service. Estimating it overpaid physician claims by $13.8 million, CMS is referring more than 484,000 such claims to RACs and other recovery entities to audit.
Mr. Spencer also expects the complex reviews will look at high level E&M services, under CPT codes 99294 and 99215, and high-level subsequent hospital visits, under CPT codes 99233. Previous studies indicate these codes have very high error rates, he says.
RACs can get an idea of easy targets by reviewing Medicare contractors' service-specific probes, Mr. Spencer says. For example, a service-specific probe by the Medicare contractor for Wisconsin determined a 96 percent error rate for CPT code 99233.
Learn more about Fi-Med Management.
Read more on RACs:
-7 Concerns About the Upcoming Implementation of Medicaid RACs
-CMS Proposes to Let States Implement Medicaid RACs in April