Virginia, West Virginia Also Added

Connolly Healthcare, the RAC for Region C, posted 20 new DRG Validation Issues to their list of CMS-Approved audit issues, on Friday, April16. The new issues include eight (8) MS-DRGs with very high Relative Weights (which equates to high dollar reimbursements and thereby potentially high RAC fees). Also, six (6) of the new issues have claim volumes in the top 25% of all DRGs (as measured by the number of discharges with that DRG nationwide). A high volume of discharges provides a corresponding large number of claims for the RAC to potentially audit.

Four of the new issues are for MSDRGs with Relative Weights (RW) of better than 10.0. One of them -- MSDRG 001, Heart Transplant -- has one of the highest RWs: 24.85.  A high RW produces a high dollar reimbursement, since the Relative Weight of a DRG is used to calculate a facility's payment. A simple approximation of a payment can be calculated by multiplying the Relative Weight by a facility's Medicare Blended Rate, a dollar amount which is calculated and assigned by CMS every year for all facilities who bill Medicare under the Inpatient Prospective Payment System. The average Medicare Blended Rate nationwide is roughly $4500. Therefore, a DRG with an RW of 10.0 would likely pay a facility approximately $45,000 per claim.

Since Connolly's contigency fee is 9.0% (by contract with CMS), the RAC's fee for a $45,000 recoupment would be $4,050.

Virgina and West Virginia Now Included

The states of Virginia and West Virginia have been absent from the list of states affected or approved for any issues, until some recent changes to the lists, earlier in April. Still, not all the issues have been approved for these two states.

The New Issues

Below are the new posted and approved audit issues for RAC Region C, including Relative Weights and FY09 Discharge Ranks:  (a low rank number relates to a large number of discharges for that DRG, and vice versa)