First Requests for Maximum Records Seen

Connolly Healthcare requested the maximum allowable number of records from many facilties in their region over the past few days, sending out Additional Documentation Request (ADR) letters immediately after posting approval for medical necessity review of 29 MSDRGs on August 30. The targeted facilities have never before seen requests for this number of records, since the permanent RAC project began.

Many facilities have received requests for the largest number of records that CMS will allow a RAC to request from a single institution, during a 45-day period. The maximum allowable number of records varies from facility to facility according to a CMS-mandated formula, and in some cases are more than 300 records. The ADR letters come on the heels of the first approvals of medical necessity reviews by the CMS New Issues Review Board, which were subsequently posted to RAC websites as early as August 13, as required by the RAC Statement of Work.

Confusing Posts

While those postings have caused confusion among many providers due to the lack of a consistent format on the sites and site designs that have often been described as difficult to use, it is evident that Connolly, and perhaps all the RACs, have simply been waiting for CMS to grant approval for medical necessity issues, before they could begin performing complex reviews in earnest and with any volume — volume that will very likely greatly improve their return on investment in becoming one of the RACs in the permanent program.

Despite the confusing posts, which Connolly has been editing daily since they first appeared on August 30, the Additional Documentation Request (ADR) letters make very clear that Connolly will be reviewing both medical necessity and DRG Validation, for the specified records. In some letters, however, only DRG Validation is called out as the issue in question.

Approved for Both Seems Likely

We have received several questions from providers, since the posts first appeared, about the fact that only some of the Connolly posts appeared to mention DRG Validation at the same time as Medical Necessity, prompting them to wonder, then, if Connolly was approved for both, or just one or the other. After a review of the posts, with the edits made by Connolly over the past days, additional review of posts made by the Region B RAC (CGI) and the reported wording of the ADRs just received from Connolly, it seems likely that Connolly is in fact approved for both types of review for the 29 MSDRGs now posted, regardless of the exact wording on the Connolly website.