Region D RAC Approved for Medical Necessity Reviews

HDI Posts No New Issues, 29 DRGs Now Approved Medical Necessity Reviews

Health Data Insights (HDI), the CMS Recovery Audit Contractor (RAC) contracted for reviews of Medicare claims in 17 western states, posted approvals for the review of both medical necessity and DRG Validation for previously approved and listed issues including 29 DRGs, effective August 16, 2010. HDI is now approved to review medical necessity for the same DRGs recently approved by CMS for CGI, the RAC for Region B. No new issues were posted by HDI, since all the DRGs involved were already approved for DRG Validation previously.

The List

Previously, it was expected that the RACs would be posting "new issues" as a way of identifying newly approved review issues. As of Friday, August 13,however, the Region B RAC, CGI, made it clear that there is no intention of posting medical necessity reviews as "new issues" unless the DRGs involved have never been approved/posted on a RAC's website before that time. HDI has shown that they fully intend to follow this same process, editing and updating older issues, rather than posting them anew.

Below are the 10 "old" issues that now include the 29 DRGs approved for review of medical necessity:

(Note: you will need to login to the eduTrax main site -- Registration is still Free.)

Changing versus Adding Issues to the Lists

eduTrax® reported previously on the new and unexpected method that CGI has chosen to "post" any issues that are now approved for review of medical mecessity. These postings by HDI now further strengthens the opinion that CMS considers this to be an appropriate method of fulfilling the RAC obligation to post approved issues, as provided for under the RAC Statement of Work.

Once again, it is clear that providers must closely monitor the RAC websites if they have any hope of being aware of the RACs are doing, and where they are looking for recoupment.

Sortable Lists

In an effort to track those issues approved for Medical Necessity, edutrax will soon unveil a new list/tool, showing only those issues approved for Medical Necessity review by the RACs.

To find a free complete, sortable listing of all currently posted issues, visit this page on eduTrax. (Registration required.) We recommend viewing the list, sorted by Approved Date.

To see the complete original listings (on the RAC websites), visit this page.

Want An Alert?

If you would like to be notified by email whenever they do get posted, simply to the click here to subscribe for free to the eduTrax RAC New Issues Alert Service®. We post new issues, as in this article, and will send out an email notice immediately when medical necessity issues begin posting on the RAC websites.