Audit round up: RACs cut checks, UPICs run roughshod

YARMOUTH, Maine - Nearly two years after Performant Recovery announced it would perform an underpayment review for Group 3 power wheelchair options, providers are receiving refund checks, says Andrea Stark.

Performant, the DMEPOS RAC, announced in May 2017 it would review wheelchair accessories, including seating systems, and seat and back cushions furnished in conjunction with codes K0848—K0864 for the six-month period of Jan. 1, 2016—June 30, 2016. The review was necessary because CMS was unable to make changes to its processing system to accommodate adjustments to the 2016 Medicare fee schedule amounts mandate.

“They weren't able to be billed properly, so they weren't paid appropriately and should have been subject to the higher amount,” said Stark, a reimbursement consultant with MiraVista. “I've had several clients get a check for a few thousand dollars, so that was pretty exciting.”

Be prepared to make your case

RACS, on the whole, aren't doing a lot of complex reviews these days, most likely due to the huge backlog at the administrative law judge level, where about half of all appeals are related to DME, says Kelly Grahovac, senior consultant for The van Halem Group.

However, providers who file appeals simply because they believe the judge will rubberstamp overturns will need to review those claims for accuracy and submit the appeal with a real argument, she said.

“The judges are getting much more training and have more understanding of policy than in the past,” said Grahovac. “That's not a bad thing—they can still make independent decisions, but they are making more informed decisions which requires the supplier to make a more articulated appeal.”

'Worse than RACs'

While the volume of RAC audits has diminished, activity from UPIC contractors is rampant, says attorney Elizabeth Hogue, especially in the West and Midwest.

“They are suspending payments to providers altogether or they are putting the on 100% prepay review,” she said. “In some respects, they are worse than the RACs. Unless you are a large agency that can withstand (not getting paid), it really just puts you of business.”

At least with the RACs, there is an appeals process to follow, says Hogue. Dealing with the UPIC—assuming you can even identify someone to talk to—is very difficult.

“There's very little recourse with regard to payment suspensions,” she said. “You an submit a rebuttal statement arguing that the suspension should be lifted, but that's a tough case to make.”