Medicare auditors challenging physician diagnoses

Medicare reviewers are delving deeper into medical decision making and beginning to question doctors' diagnoses when they audit claims, according to Report on Medicare Compliance.

Diagnosis-related group (DRG) validations and medical-necessity audits are much more intense, according to hospital compliance officers. Some recovery audit contractors, RAC-like auditors, Medicare administrative contractors (MACs) and Medicare quality improvement organizations (QIOs) are even rejecting claims because they don't agree with the physician's diagnosis or with the need for a procedure.

According to RMC, in some cases, claims are denied, because the physician didn't base the diagnosis on clinical guidelines, whose use is not required by Medicare.

In one case, the RAC said that the medical records didn't support acute renal failure as the secondary diagnosis. In another, a RAC-like auditor rejected an aspiration pneumonia diagnosis, claiming a lack of specific imaging evidence.

Audits, it seems are going deeper than the usual documentation expectations. RACs aren't following coding guidelines and just checking documentation, said Becky Cornett, director of fiscal integrity at Ohio State University Medical Center.

In the past, auditors focused on whether charts contained proper documentation--such as physician orders, and whether they were signed and dated and specific to the services delivered--said Kevin Cornish, national director of the healthcare dispute, compliance and investigation practice for Navigant Consulting. "Now it's 'what was the diagnosis, what was the history, what tests were run, what decisions were made in terms of the procedures performed, and was it consistent with Medicare requirements?'"

To learn more:
- read the Report on Medicare Compliance article

Related Articles:
AHA: RAC activity, audits up
RAC lessons: Appeals can work; denials and hospital prep are costly
RAC audits will cover Medicaid, Medicare Parts C and D
CMS' failure to act on RAC findings has resulted in $231 million loss

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