Pain diagnoses may be red flag for RACs

Revenue audit contractors are zooming in on hospital charges to treat both back and chest pain as the most likely sources of rejecting claims, according to a presenter at the Healthcare Financial Management Association's Annual National Institute.

Up to 30% of back and chest pain treatment claims were coming under the scrutiny of both MACs, including audit prepayments and RACs, which cover post-payment scrutiny, said Robert Corrato, MD, chief executive officer of Executive Health Resources in Newtown Square, PA, during a Monday presentation.

"There's no sheriff in town, and it's like the Wild West out there," Corrato said. He noted that there is about $80 billion in revenue lives in what he calls a "gray zone," posited on whether the care rendered was medically necessary or not. Back and chest pain treatments are a target because they're tough to defend as medically necessary, and many RACs are focusing on those charges, leading others to do the same, he said.

In addition to chest and back pain, Corrato said that observation stays and short (one-day) stays are likely to draw the most scrutiny.