The updated SOW also places an emphasis on the fact that RACs are expected to give CMS feedback on areas where guidance is unclear, which—down the road—could ultimately be quite beneficial for providers. Take LCDs (local coverage determinations), for example. The updated CMS guidance states:
The majority of coverage policy in Medicare is defined through Local Coverage Decisions (LCD). Therefore, LCDs typically provide the clinical policy framework for Recovery Auditor medical necessity reviews. If a LCD is out of date, technically flawed, ambiguous, or provides limited clinical detail it will not provide optimal support for medical review decisions.
CMS states in the SOW that RACs are using guidance in the LCDs for medical necessity decision making, and that the RACs will be tasked with helping CMS and the other contractors to improve that guidance over time, according to Taylor.
"So what could be an outcome of that? It's possible that we may begin to see the evolution of more specific types of medical necessity guidance, which would make the hospitals' jobs a lot simpler," he says.
Complete denials vs. partial denials
Although it is not a change from the previous program, CMS now states that a recovery auditor may find a full or partial overpayment, but it is now written in such a way that suggests that the contractor should be denying the overpayment, but permitting payment for the lower level—and medically necessary— level of care, says Taylor.