The Centers for Medicare & Medicaid Services (CMS) recently released Transmittal 311 (Change Request 6684) providing instructions to Program Safeguard Contractors (PSC) and Zone Program Integrity Contractors (ZPIC) on entering suppressions and exclusions into the RAC Data Warehouse.
CMS established the RAC Data Warehouse to track the activity of Medicare Recovery Audit Contractors (RAC) and prevent conflicts between RAC reviews and other Medicare program integrity activities. Transmittal 311 provides some further insight into how suppressions, exclusions and the RAC Data Warehouse may work. For instance, the manual changes imposed by Transmittal 311 state:
Transmittal 311 also provides suppression and exclusion examples.Subscribe to Medicare Update, follow me on Twitter @MedicareUpdate, and become a fan on Facebook."To prevent RAC interference with active investigations or cases, PSCs or ZPICs shall enter suppressions in the RAC Data Warehouse to temporarily mark entire providers or subsets of a provider's claims as off-limits to the RACs. Individual claims that have been previously reviewed (or that are part of an extrapolated settlement universe) shall be excluded to permanently block them from repeat reviews by a RAC."
"The RAC Data Warehouse allows users to enter suppressions on any combination of provider ID, DRG, ICD-9 procedure code, HCPCS code, state or zip code, although CMS requires that suppressions be tailored as narrowly as possible. PSCs and ZPICs shall suppress targeted procedure codes from specific providers associated with open investigations/cases; suppressions of one or more procedure codes across an entire geographic area may be considered in egregious situations of widespread fraud and abuse of specific codes or types of services (e.g., infusion therapy in South Florida)."
"In designated high-risk areas where particular categories of providers are under scrutiny by law enforcement, the PSC or ZPIC may also suppress at the provider level..."
