Does your RAC compare Medicare A and B claims?

tmcginn@northshore.org

Hi everyone,
I have been hearing from one of our vendors that some RAC regions are currently able to compare or reconcile Medicare Part A and Part B claims to evaluate for a mismatch. For example, a physician bills his E/M services out using a supporting dx of aspiration pna, but only documents "pna" in the hospital chart, resulting in the hospital billing out in DRG 193-195 while the physician bills for a more complex illness.

When searching online about these activities, I have found articles and information that makes it unclear to me if *only* the physician's fees (using my example above) are intended to be the repayment target - or if *both* the physician and the hospital are at risk for financial loss when there is a mismatch.

Does anyone have personal experience yet with these activities to shed some light on the situation? Thanks...

Tricia McGinn, MBA, BSN, RN
Director, Documentation Integrity
NorthShore University HealthSystem
4901 Searle Parkway, Suite 330
Skokie, IL 60077
Phone: 847-982-4212
tmcginn@northshore.org

kshumpert

I think that it is the ZPIC that looks at both Part A and Part B. They are looking specifically for fraud and I don't think they receive a contingency fee like the RAC does. We have not had any of these audits, but I think I remember hearing something about both the hospital and the physician's office sending out the records in a timely manner and if not payment can be denied. I briefly go over ZPIC with the physicians just to let them know that their staff needs to be aware of what is coming in the mail and address it timely or no payment!

Thanks,
Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Cell phone 765-432-3961
Fax 765-453-8447

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