CMS 'complex reviews' on the way by August/September

So, everyone's been bracing themselves for full-bore audits by Recovery Audit Contractors--but soon the anticipation will end. CMS has already begun automated reviews of claims to detect simple, obvious issues, but the real in-depth audits--known as "complex reviews"--are on the way very soon.

The agency has announced that it will begin complex reviews for DRG validation, as well as for coding errors, in August or September of this year. Going into fiscal 2010 (October 2009) it will begin complex reviews for durable medical equipment medical necessity, then follow with such reviews for medical necessity.

The medical necessity claims are likely to give provider execs the most gray hairs, as it's easy to get into a shouting match about such matters, but all of the complex reviews are likely to lead to challenges that aren't terribly easy to fight.

One mercy is that CMS requires RACs must offer educational outreach sessions prior to beginning audits in a particular state. Want to bet that those will be packed--standing room only--with people listening in the hallways?

To learn more about upcoming RAC reviews:
- read this Health Leaders Media piece

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