A Hodgepodge of Issues

Complaints about RACs may have waned, but there are still plenty of topics to cover as it pertains to their audits.

Let me start with a follow-up to something I reported last week on Monitor Mondays. I noted that in New York City, the retired municipal workers are upset that they are being forced into a Medicare Advantage (MA) plan. Well, it turns out that what the city actually did was form its own Medicare Advantage plan, specifically for these workers. They had to design it as an MA plan to get all the regulatory protections that MA plans get. As a result, unlike most MA plans, the enrollees can go out of network and still get their care covered. It will be interesting to watch, as this model of customizing an MA plan for a specific group of enrollees develops. If successful, it may provide some relief for the many government entities with large retiree healthcare costs.

Next, I want to call out Blue Cross Blue Shield of South Dakota for publicly misinterpreting a regulation. They sent out an email last week saying that the No Surprises Act requires all providers to review their provider directory listing once every 90 days to ensure its accuracy. Then, 45 minutes later, they recalled that email, noting that their system does not currently allow providers to log in and review their data.

But they are wrong.

There is no such provision in the law. The law requires health plans to check the accuracy of their provider directory every 90 days, and places no obligation on providers to do anything. They were right to pull the email, but it is best to admit a mistake rather than trying to cover it up.

Next, last week a listener asked why it is called “RACmonitor” if we rarely discuss the Recovery Audit Contractors (RACs) and audits in general.

And it’s true, the topics we cover have evolved over time. The RACs are still out there auditing, but at least for me, I rarely hear a complaint about their activities. They seem to be auditing away, but not with the gusto and blatant disregard for rules as they did in the past. In fact, they have not asked the Centers for Medicare & Medicaid Services (CMS) for permission to audit a new issue in several months. Likewise, the COVID-19 pandemic did stop or slow all auditing considerably, by every audit agency, so there is currently a paucity of topics to discuss. That said, we want to hear about what audit travesties you are seeing, and what’s frustrating you. Email us, send me a tweet, and type it in the questions section. We want to talk about what you want to hear about.

Finally, one thing we don’t talk about enough here is the healthcare received by our veterans. As you know, most veterans receive their care at U.S. Department of Veterans Affairs (VA) facilities. And questions are often raised about the quality of care provided to veterans at such facilities. Well, a study released last week attempted to answer that question. The researchers looked at medical care received by veterans who had an emergency medical condition and were taken to either a VA or a non-VA hospital, and the results showed that those taken to the VA had a 46-percent lower risk of mortality over the next 28 days. Of course, there are confounding factors, but it certainly is reassuring to know that our veterans are getting excellent emergency healthcare.  

Programming Note: Listen to Dr. Ronald Hirsch live as he makes his Monday rounds on Monitor Mondays, 10 Eastern and sponsored by R1-RCM.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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