Some of the patients Tenet Healthcare billed for from May 2005 through December 2007 “did not meet the standards to qualify for an IRF admission,” the Justice Department stated.

 

Tenet Healthcare disclosed the information “as required under its corporate integrity agreement,” according to a statement from Inspector General Daniel Levinson in the Justice Department announcement.

 

For more information on the settlement, visit http://www.justice.gov/opa/pr/2012/April/12-civ-446.html.

 

RAC Posts Two Issues

 

CGI, the Region B recovery auditor (RAC), posted two issues – one for inpatient hospitals and one for outpatient hospitals. For more information, see the chart below.

 

Inpatient hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Minor musculoskeletal procedures (MS-DRGs 479, 484, 494, 497, 499, 502, 508, 509, 512, 517)

3/26/12

RAC Region B

The purpose of this complex review is to identify claims that have been reviewed validating medical necessity in short stay, uncomplicated admissions. This review will identify if medical necessity was met per Medicare guidelines.

Medicare Benefit Policy Manual chapters 1, 6, 10; Medicare Claims Processing Manual chapter 4; Medicare Program Integrity Manual chapters 6, 13; OIG reports A-03-00-00007, OAI-05-88-00730, A-01-10-01000; 2009 Report to Congress on the Evaluation of the Quality Improvement Organization Program; Pepper report; WPS LCD DL32222; Highmark LCD L27548; Social Security Act section 1886(d)

 

Outpatient hospitals

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Hyperbaric oxygen therapy excessive units

3/22/12

RAC Region B

The purpose of this semi-automated review procedure is to identify claims that reported excessive units for hyperbaric oxygen therapy, HCPCS code C1300. Hyperbaric oxygen therapy is not expected to exceed 90 minutes so units reported should not exceed four.

WPS LCD DL31357; MLN Matters article MM3632; Hospital outpatient prospective payment proposed rule released July 18, 2011

 


 

About the Author

 

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation’s leading independent authority on home healthcare business, regulation and reimbursement.

 

Contact the Author

 

KLong@decisionhealth.com

 

To comment on this article please go to editor@racmonitor.com

 

Medicaid RACs’ Effect on the Program Integrity Landscape

 

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