In previous posts, we’ve reported that two RACs have now posted approval to begin reviews of both medical necessity and DRG Validation, for the exact same 29 DRGs.  We have also previously shown that the RAC lists (as posted earlier this year) are skewed toward high-dollar and high-volume claims, to no one’s surprise.

Nevertheless, we have a “new” list, so let’s take a look at this “List of 29,” let’s call it — the first list of MS-DRGs approved for RAC review of medical necessity. Can we learn anything about what the RACs and CMS are thinking?

The answer is YES, we can.  Click here if you just want to jump down to the conclusion…

How Skewed Is This “List of 29″?

Well… not very, but that’s actually worse for providers! Why is it worse? Read on, and it should be come clear…

The first table below begins with some unfortunate insight, when counting the number of CC or MCCs in the List of 29. If you are not too familiar with the MS-DRG system, we recommend reading a PDF made available by CMS on the system.

Briefly, the Medicare Severity-Diagnosis Related Groups (MS-DRGs) are a system of codes that provide up to three levels of severity for a particular condition or diagnosis. A “Base DRG Group” combines all levels of severity into a single category, allowing us to combine the the individual MS-DRGs for reporting. Individual MS-DRGs within a Base DRG Group are differentiated according to the presence of either a complication (CC) or a major complication (MCC), or neither. Some Base DRG Groups, however, happen to have only two codes assigned to them. At the end of the day, all the MS-DRGs are assigned payment rates, based on their relative use of resources and supplies. Simply put, a condition that is accompanied by a major complication (MCC) is more costly to treat, therefore the provider is paid more for that claim. A condition with a complication (CC) is not paid quite as much, and a condition with neither CC nor MCC is paid the least of the three.

Now consider this table and consider what the numbers reveal:

• 8 or 28%   – the number of MS-DRGs without a CC or MCC
• 13 or 45%   – the number of MS-DRGs with an MCC
• 18 or 62%   – the number of MS-DRGs with either a CC or MCC.

For the sake of this article, let’s just assume that all Base DRG Groups include exactly 3 MS-DRGs: one with an MCC, one with a CC, and one without CC or MCC. If that were true, then any randomly selected list would likely have 33% of each kind of MS-DRG. However, if the list of MS-DRGs was selected with a weighting toward the MS-DRGs with an MCC, then there would be a higher percentage of those in the list, and a lesser percentage of the two others. Basically, any list with one type of MS-DRG appearing more than 33% of the time is evidence that selection of the list favored that type of MS-DRG over the others.

In the above table, MS-DRGs with an MCC appear 45% of the time, and therefore is evidence that the list is skewed toward those MS-DRGs with an MCC. So, as mentioned above, we can once again demonstrate that even this new list is skewed toward the higher paying MS-DRGs, particularly the ones with MCCs. Of course, this still comes as no surprise, since the RACs are paid via contingency fees — the more they find, the more they get paid by CMS.

But I’m not done yet.

The size of the “skew” was disappointing, and something else about those numbers just didn’t sit right with me. The “skew” just wasn’t very big. I was expecting more. And why were there so many lower-paying DRGs in the list? “Whassup with that?” as my teenage daughter would say.

Could it be that the list is not really intended to be very skewed? That’s when the pattern became clear to me, and a reason for that pattern also came to mind…

RAC to CMS: “Hey, it’s all good!”

The RACs have obviously been busy, these past months. They were not sitting idly by, waiting for medical necessity to be released. It appears to me quite obvious that they have been running their little data-mining machines in high gear because it seems that they have dredged up plenty of evidence of improper payments due to what will be defined in denials as “a lack of medical necessity.”

Remember, the only thing that matters to a RAC is the documentation, or the lack there of, to clearly demonstrate medical necessity, not the reality of the patient encounter. And to get approval from CMS to pursue an issue across their region, a RAC must gather enough evidence to make a case that there is a problem with said claims.

I kept staring at the list. A pattern became obvious to me. Perhaps the pattern is obvious to you, too, but I’ve neither seen nor heard anyone else mention what this pattern MEANS for providers, and I do think it is important to recognize, to enable more clear thinking about what the RACs and CMS intend to do.

A Pattern Emerges

The table below shows the pattern: six complete DRG Groups, included in the List of 29. That’s 16 DRGs, more than half of the list. And remember, these are high-volume DRGs…

What this means is that for these specific diagnoses, CMS and the RACs have evidently found enough evidence to warrant RAC reviews for the medical necessity of these treatments for ALL such claims, not simply the higher paying ones.

Does this mean that CMS actually believes that the patients really did not NEED these treatments? Doubtful.

Or, does this mean that CMS is willing to argue with physicians about the medical necessity of treating these conditions or that they have been misdiagnosed?  Perhaps this is true, for a few cases; but I even find this doubtful, although to read some articles out there, one would think that physicians are preparing to wage war on who-knows-best-how-to-care-for-patients with the RACs’ medical directors. While such battles will inevitably occur, it would seem to me that this is not the kind of evidence that the RACs have already found and used to convince the New Issue Review Board at CMS to approve reviews for all the MS-DRGs in these six Base DRG Groups.

Here is what I think it more likely means: the RACs have found enough evidence to support the assertion that providers are recording neither appropriate documentation nor enough documentation in the medical record to warrant reimbursement for services provided to Medicare beneficiaries in their facilities, and that the problem is so ubiquitous that it bears scrutiny across almost the full spectrum of DRGs. Remember, HDI already has approval for DRG Validation for about 80% of all MS-DRGs.

I’m neither an expert on medical necessity nor on auditing medical records, but I do know how to analyze data and find patterns and meaning in those patterns. To me, this latest list simply nails the issue. This is not about medicine. It’s about money.

HDI Edits Ten Issues to include Reviews of Medical Necessity for 29 DRGs

The Region D RAC, HDI, only took about a week to also garner approval to begin review of medical necessity for 29 DRGs previously approved for DRG Validation, after the Region B RAC, CGI, was approved by CMS to begin medical necessity reviews for the same DRGs, as of August 6, 2010. However, while CGI had to post six (6) new issues to their site, because those DRGs had never appeared on their site before, HDI did not have to post any new issues. Of the existing 746 MSDRGs, HDI had already posted approvals for DRG Validation of over 75% of them, and these 29 did happen to already be among their approved list.

The I’s Have It: CGI and HDI

Now two of the four RACs have approval to review medical necessity, putting 24 states under such review. We do expect that to grow in the next few days, since it took HDI only about a week to catch up to CGI, so we assume Connolly and DCS are not far behind.

Although our previous post provided lists and links to the 29 DRGs, those links and titles were created using the CGI website data. Also, that list was broken into two lists — one for “new” issues, and one for “previous” issues.

Below is a list of the ten “previous” issues that now include some approvals for medical necessity. It was created using the HDI website data, which is slightly different. To see the full detail, as posted by HDI, follow the links:

(Note: to see the details, you will need to login to the eduTrax main site — Registration is still Free.)

Most Difficult to Track

It is perhaps insignificant but notable that the first two RACs to be approved for medical necessity review also happen to have the two websites that are the most difficult to monitor for changes. Both sites are constructed in a way that requires interaction, and does not provide a simple method of capturing the data on the page, to compare to a future capture of the same page.

New Service Coming

We have resorted to creating our own software application to specifically follow and compare all the pages on these two sites. Shortly, we will announce and offer a for-fee service to notify our clients and subscribers of any changes posted to any of the RAC New Issues pages, including the details screen, in addition to our eduTrax RAC New Issues Tool Suite®.

CGI Federal, the CMS RAC for Region B posted approvals for review of both Medical Necessity and DRG Validation for some 29 DRGs since last Thursday, August 12, 2010.

Half of the top 20 DRGs nationwide were included. Click here to jump down to the list.

Our subtitle above calls these “Newly Approved,” instead of “New.”  Why did I use that phrase?  Why not just say “new”? Well, because that’s not quite accurate, and it seems that CMS and CGI don’t consider all of them to be “new” issues. Are you surprised that a word like “new” is not well defined?

This little video snippet should help you recall recent public debate about what the word “is” means.

I’ve had “debates” like that, on occasion, and I’ve always wanted to ask the person debating with me, “How many moons are in your night sky?” Of course, some words change definitions over time, or just mean different things to different people. Small words should be easy to define, though, don’t you think?

Anyway, keep this in mind as you read on, because there does not seem to be a consensus in our industry on what the word “new” means.

More about this later…

A Valid “New” Concern for Providers

The morning after the “newly approved” medical necessity issues were first posted by CGI, I spoke with the a RAC Team Leader for a hospital system with hospitals in several states. Even though this system has no hospitals in Region B, I know this person as a keen observer of all the RAC activities, and we often talk about the impact of the RACs. “We heard from our state hospital association that Region B would be the first to post some issues for medical necessity, and that it would happen this week,” they told me. “So, this wasn’t really a surprise. But this marks a new phase for the RACs, and we are concerned about what’s on the list.”

50% of Top 20 DRGs Now Approved

A quick analysis of the list proves that provider concerns are quite valid – of the top 20 DRGs for FY2009, 10 made this new list. Therefore, perhaps half of the top 20 DRGs in any facility either are now or soon will be targets of RAC reviews for medical necessity; and remember, they were already likely targets for reviews of physician admission orders, DRG validation, and the coding for principal and secondary diagnoses.

The First “New” DRGs Approved for Medical Necessity

Now, let me explain a small caveat, about the word “new”:  some of the DRGs approved for Medical Necessity are truly “new” issues, as those DRGs have never appeared on the (CGI) list before; while other DRGs were already approved for DRG Validation, but have now been “newly approved” for Medical Necessity review, as well.

So now, here is a list of six (6) issues with nine (9) DRGs never before posted on the CGI website, but now are posted as approved for review of both Medical Necessity and DRG Validation. To see the full detail, as posted by CGI, follow the links:

(Note: to see the details, you will need to login to the eduTrax main site — Registration is still Free.)

• MSDRG 253, 254: Other Vascular Procedures w CC, w/o CC/MCC
• MSDRG 302: Atherosclerosis w MCC
• MSDRG 312: Syncope & Collapse
• MSDRG 313: Chest Pain
• MSDRG 314, 315, 316: Other Circulatory System Diagnoses
• MSDRG 811: Red Blood Cell Disorders w MCC

There was also one DRG added for the first time, but only approved for DRG Validation:

• MSDRG 813: Coagulation Disorders (Medical Necessity excluded)

Ok, but that’s still only nine of the DRGs. Where are the others posted on the site?

Twenty More DRGs with Medical Necessity “Newly Approved”

The other 20 DRGs now approved for Medical Necessity review were all listed previously for DRG Validation in a total of 12 issues, dating back to December, 2009, among the first complex reviews posted by CGI. These 20 DRGs were not listed as “new” issues, but were simply “called out” as approved for Medical Necessity by renaming those previously approved issues.

The 12 issues with some DRGs newly approved for medical necessity review are as follows:

• MSDRG 056, 057, 069: Nervous System Disorders
• MSDRG 190, 191: Chronic Obstructive Pulmonary Disease
• MSDRG 192: Respiratory
• MSDRG 249: Percutaneous Cardiovascular Procedures
• MSDRG 291, 292, 293: Heart Failure & Shock
• MSDRG 308: Cardiac arrhythmia & conduction disorders
• MSDRG 391: Esophagitis gastroenteritis and misc digest disorder
• MSDRG 393: GI Disorders
• MSDRG 551, 552: DRG Validation for Musculoskeletal Disorders
• MSDRG 640: Nutritional & Metabolic Disorders
• MSDRG 682, 683, 684: Renal Failure
• MSDRG 689: Kidney & Urinary Tract Infections

Confused yet?

Why Not List All Those As “New Issues”?

Why indeed!  NOW, with the lists out of the way, let’s finally discuss why I even bring this up, and why it really will matter to providers — at least the ones who are trying to keep up with what the RACs are doing.

“New” Issues Must Be Posted by the RAC

According to the RAC Statement of Work, before a RAC can begin sending out requests for documentation to conduct complex reviews, or even demand letters for automated reviews already completed, the RAC must first win the approval of any audit issues from CMS, and then they must post all those approved issues on a public web site.

Last August, we all began watching those websites ominously take form and grow by leaps and bounds, in some cases, with the addition of more and more “new,” approved issues. We were curious to see the formats that the RACs were using, as each seemed to have their own private format for posting the issues.

Why Not All Use the Same Format?

Because they don’t have to. The RAC Statement of Work actually says NADA about what the format of these websites should be, and how “approved issues” should be “posted” on the sites. Whence, each RAC has their own interpretation of how to “post” their “new,” dare we say “newly minted,” approved issues.

To be sure, Medical Necessity review was never approved by CMS for a RAC before August 6, (now there’s an ominous date for you) and no issue approved for medical necessity review has being posted on any RAC website before August 11. However… now that such approvals have been garnered, and such posts have been made, at least some of said posts have been done in a manner that could be described as… well… obscure.

I call them obscure because some of these posts wind up as simple “edits” instead of “new” line items.

The method that CGI has chosen for posting approvals of Medical Necessity reviews is either of two methods: 

1. post it as a new issue if the DRG is not already on the list; or
2. merely change the name or title of the previously approved issue that lists the DRG, to include Medical Necessity review for one or more of the already approved DRGs in that issue.

So, some 20 of the 29 DRGs wound up “sprinkled” within 12 older issues, and simply had their titles “edited” instead of appearing as “new” line items in the list.

Why does this matter? Because the RACs can now post changes to their list of approved issues, without notice. Of course, they didn’t have to notify any of the providers before, but the lists seemed to do that, after a fashion – a form of notifying providers of what’s being reviewed, what to expect from the RACs.

Since the lists first appeared, many of us were thinking that we could watch the RAC websites and see the “new issues” get posted, from week to week; hoping we could simply sort the list (somehow) by date posted, and we’d know if there was anything “new” on the list or not.

“We all” were wrong. It would seem that “new” doesn’t have the same meaning, as we now see with the way a “new” review approach (medical necessity) is embedded in the original posted issue. Keep in mind that there is no reason to think that the other RACs will not adopt this same approach, also. Instead of posting “new” issues for Medical Necessity, they may simply rewrite the descriptions of their “old” issues, just as CGI has done.

Anyway, more “new”…oops… “edited” issues can be expected, any day. They’ll just be harder to track now, because we’ll have to read every issue, every day, to see what changed.

Oh, and by the way, I only see one moon in my night sky — how about you?

The List

Below are the nine new issues, posted earlier this week. Follow the links to each one, in the eduTrax RAC New Issue Database®, which can be seen with simple free registration at myedutrax.com.

Who’s Getting Stuck?

You’ve billed for it, even been paid for it. But will you get to keep the money? And you can’t take the injection back…

This is like getting an injection with a barbed needle: feels ok going in, but coming back out it hurts like <insert your favorite expletive>.

For both providers and payers, there’s no confusion about one thing: injections and infusions can be tricky to properly bill.

Instruction Available

The eduTrax® site has two excellent courses available for their paid subscribers, and these can also be purchased as downloads or CDs. Short previews are available to give you an idea of their quality and content:

Coding Injections and Infusions — reviews the recent changes to injections and infusions codes and offers guidance on correct capture of these services. (3 minute preview)

RAC Focus: Injections & Infusions — discusses why, how & where physicians must be involved, and addresses code selection based upon time and service provided. (8 minute preview)

Click here to send us an Email for more information or to place an order.

Still No Medical Necessity Approvals

To date, there are still no issues posted & approved for review of Medical Necessity for any issue.

As usual, we wait…

The List

Below are the 15 new issues, posted last week. Follow the links to each one, in the eduTrax RAC New Issue Database®, which can be seen with simple free registration at myedutrax.com.

More to Come

We’ll have more to say about the review of Physician orders, soon…

Equipment Available before passage of the Healthcare Reform Act of 2009

After bringing  a False Claims Act case to the attention of federal agencies, a Florida whistleblower remained working at WellCare Health Plans offices and then even went so far as to wear a hidden wire (probably just like you see on television) during business meetings, helping the Justice Department (DOJ) in an 18-month undercover operation to capture evidence of alleged fraudulent practices by WellCare officers and employees.

All of this has come to light as of June 25, 2010, when a U.S. District Court judge ordered the complaint unsealed. The original complaint is still not available, but the complaint filed on June 21, in the US District Court for the Middle Florida District, is now available.

(Find it here and other documents related to the case here.)

Might we see an episode of Law & Order soon with this kind of a case? I think it’s pretty gutsy to wear a wire for the Feds, but in this case, the pay-off is much more than just “doing the right thing” or even protecting future victims. Whistleblowers get pretty hefty pay-days, with or without a wire. Perhaps the investigators used that pay-day as a carrot? Wear a wire, get more evidence, you get a bigger pay-day?

Wait… A Settlement was Reached?

Three years later, WellCare reportedly announces that it has agreed to a “Preliminary Settlement” with the Department of Justice, Civil Division, to pay $137.5 million to “settle their pending inquiries.” (Notice that there is no mention of any criminal inquiries…) You can see what WellCare filed with the SEC about this, here. (We can’t seem to find any documents from WellCare or the government, yet, about this supposed settlement.)

Evidently, the whistleblower was not invited to the negotiation where a  settlement was reached, and understandably is not keen on the mere $137.5 million settlement that the government has agreed to with WellCare. According to the whistleblower’s attorney, “…the proposed settlement would permit taxpayers to be unfairly disadvantaged by a settlement that pays less than half of what our pleadings suggest was stolen, to say nothing of the requirement of triple damages under the False Claims Act.“  The attorney and his client estimated that WellCare received over $400 million to perhaps as much as $600 million in fraudulent payments, from a combination of Medicaid and Medicare programs.

Since whistleblowers get 15-25% of the total penalties and damages paid by the offending party, it’s pretty easy to see why this whistleblower is upset — he could be missing out on 15-25% of perhaps as much as $800 million.

The $137.5 million, however, is still only “preliminary” and must be approved in court. We’ve searched the web and there are yet no announcements by the DOJ or any of its Civil Divisions, nor by the OIG or the FBI, related to this settlement. One has to wonder, how did they arrive at this number, which is so much smaller than the alleged frauds? Oh, and, what about penalties and damages? Aren’t those supposed to be added on?

Even if the whistleblower’s figures are inflated, there still appears to be significant fraud. Did the FBI not find much then?

Where’s the beef?

According to several news reports, the DOJ amassed over 1,000 hours of audio and video evidence of alleged fraudulent conduct by WellCare. The whole investigation took almost four years, and included a raid by over 200 federal agents from the FBI, DOJ and the OIG, on the WellCare Tampa headquarters, where they seized many computers and files.

In the complaint, the whistleblower alleges that WellCare purposefully and knowingly over-billed the seven states that it contracted with as a Medicaid HMO. It appears that WellCare used accounting “tricks” to move money around to inflate costs, thereby avoiding having to pay back monies to the state Medicaid programs.

One of the most distrubing allegations concerns WellCare’s apparent complete lack of compassion and utter arrogance in handling care for a large number of newborn babies. One of the examples cited by the whistleblower involved not only unlawfully denying care to 475 newborns for the purpose of eliminating the costs of caring for them, but then rewarding the staff who executed those denials (and perpetrated the fraud) by honoring them with a large, expensive corporate dinner meeting.

Read the complaint, form your own opinion. But keep in mind, the government has yet to file ITS complaint.

But Wait…There’s More

This has been going on for years, now. So, one wonders, what happened to the WellCare officials who (allegedly) perpetrated these frauds?  According to at least one news report, they have all been replaced since then, and there is an ongoing criminal investigation into former executives accused of committing  frauds.

Nevertheless, there also appears to be an ongoing feud between the press — specifically Health News Florida — and the Florida state Insurance Commissioner Kevin McCarty, about the whole case. Health News Florida reported on July 1, 2010, that McCarty sent them a letter saying there is “no question” that some of WellCare’s dealings (under former management) were illegal, but that the whistleblower complaint also included “unfounded allegations.”

“Unfounded” or not, someone else in the Florida state government is still very concerned about all that fraud and wants somebody prosecuted: after the whitstleblower complaint was unsealed, the Florida secretary of healthcare administration sent a letter to Florida’s Attorney General and urged him to “investigate and attempt to prosecute officials at WellCare.”

We’ve seen this question from several providers, recently. The short answer is “Yes,” but under certain circumstances, it’s “No”; and so maybe the answer should be “Maybe”?

Timing is everything, in…

Timing, Timing, Timing

In the retail industry (and others), the three most important factors are said to be, “Location, Location, Location.” If that’s true for those industries, then perhaps something similar can be said for our industry, under the new healthcare reform environment.

I submit that at least in dealing with the RACs, the factors might be, “Timing, Timing, Timing.”

Timing is everything, in many things, don’t you agree?

So let me explain what I mean…

How RACs Perform Reviews

RACs have to get issues they want to review approved by CMS before they can do “widespread review” — the term “widespread” evidently refers to multiple records, multiple providers, and/or multiple states. (They can review ANY record on a very limited basis while assembling evidence needed to garner CMS approval for any issue, but that’s another subject…)

Approved Issues Lists

The RACs also have to post a list of approved issues on a public web page, before they can begin conducting records requests, conduct reviews and publish their results — most often in the form of Demand Letters, recouping the payments from the providers.

Once an issue is approved by CMS and posted on the RAC’s website, the RAC uses proprietary software and their own experience to do data mining and analysis of Medicare Part A and Part B claims, which CMS makes available to them. When the RAC identifies claims that they believe show a potential for an improper payment, they can perform one of two types of review: an Automated review, where an error is a certainty just from data analysis; or a Complex review, where an error is considered likely, but cannot be determined without a human review of the medical record for the claim in question.

For an Automated review, the error is certain, by definition, so a Demand Letter is produced and sent to the provider. For a Complex review, an Additional Documentation Request letter (ADR) is send to the provider, and requires the provider to send specific claims records to the RAC for review. The ADR must name the issue being reviewed by the RAC. It must list one issue, and this issue must already be approved by CMS and posted on that RAC’s approved issues web page.

Now, back to the question at hand:  once a RAC recieves a record in house, can they review it for other approved issues at the same time?

The CMS Answer

Here’s how the CMS RAC FAQs answer that exact question: READ CAREFULLY…

Question: Can the Recovery Audit Contractor (RAC ) do a medical necessity review on a claim that they originally reviewed for DRG validation?

Answer: At this time, if the RAC has already requested documentation and issued a review results letter to the provider for a DRG Validation, the RAC will not be allowed to re-review the claim again for medical necessity. However, if both issues are approved (DRG Validation and medical necessity) prior to the request of the additional documentation, the RAC may conduct both reviews simultaneously.

(see Answer ID 10007, posted 4/23/2010)

Let’s analyze this a bit…

So that’s…At Least Two Answers?

First, notice the phrase, “At this time,…” So, CMS might change their policy at a later date. Form your own opinion about the likelihood of that.

Second, while the first sentence mentions the review results letter, which appears to place a stop on multiple issue reviews on a claim (that was the NO answer), the second sentence allows multiple issue reviews on the same claim, as long as both issues were approved for review before the ADR was sent out for that claim (that’s the YES answer).

So, as long as both issues were approved for review before an ADR was sent out, it appears that a single claim can be reviewed for multiple approved issues.

However, if a new issue is approved after a Review Results letter was sent out for a previously approved issue, the RAC is not allowed to re-review that same record for the new issue.

And Maybe a Third Answer?

What the statement does NOT address is this: can the RAC send out a new ADR for the same claims, under the newly approved issue? (That’s what I call the MAYBE answer.)

Well, we would expect that the RAC could submit an ADR for any approved issue, even if the record has already been reviewed for something else… but we’re going to send this question in to CMS and see what their answer is, which we will then post here…

So, stay tuned.

Region B

CGI Federal added two new issues: one Automated Review and one that includes 3 DRG Validations:

Knee Orthoses — concerns certain additions not being separately payable.

MSDRG 239, 240, 241: DRG Validation for Amputation for Circulatory System Disorders Except Upper Limb and Toe.

This site remains the most difficult to track – it is designed to require human interaction across eight pages of issues.

Region C

Connolly Healthcare posted 19 new issues, including 21 new DRG Validations:

Region D

Even HDI added a new issue for Automated Review:

Part B Duplicates – Automated Review

When Will Medical Necessity Reviews Begin?

No one knows but the RACs, and so far, they ain’t sayin’.

BUT — If you would like to be notified immediately whenever they do get posted, simply to the click here to subscribe for free to the eduTrax RAC New Issues Alert Service®.

We post new issues, as in this article, and will send out an email notice immediately when medical necessity issues begin posting on the RAC websites.

“Musical” Change and Interpretation

When CMS started the pilot RAC program several years ago, few providers outside of the demonstration states paid any attention, if they had even heard of the initiative. A few more providers and organizations (very few) began to pay some attention when the first ‘big notes’ of CMS financial opportunity and recovery began to be sounded, and by the time the program was ‘made permanent’ the ability to influence or re-write the song for providers was past.

Jazz is a wonderful and uniquely American music form, many contributing nationalities, ethnicities, generations have allowed it to morph, grow and expand to the amazing ‘melting pot’ of sounds so many of us enjoy. However the path to growth and inclusion into this form of music has not been easy for individual musicians, bands, clubs, or communities. Places like Memphis, Nashville, Harlem, New Orleans and how many others have seen those ‘pushing the bounds’ of musical genius or musical mediocrity harassed, ignored, shunned or taken advantaged of? Change and interpretation of the ‘standard’ way of approaching or enjoying musical expression has not been without resistance and controversy or without outrage in some instances.

RAC  ‘Music’

Since the 60’s Medicare has been the songwriter if you will of overall payment for certain healthcare services to a defined beneficiary population here in the US. The song has been changed, re-written, melody (?!) redundant or sycophant, with so many new song writers. The goal all along has attempted to meet the growing needs of the population and to ‘sing’ in such a way that the participant providers who share the payment song will continue in the band. So now another new refrain has been added, the RAC music. Depending upon the ‘listener’ the music may be; dissonant, off key, flat, loud, over whelming, and downright awful; however other listeners may find the notes struck timely, relevant, ‘new age’ and important.

Regardless of your perspective, exposure to the various music forms allows listeners to appreciate the facets of the current world; I was not a fan of RAP music when it first appeared on the music scene and still don’t find it a favorite of mine, however it is expressive and relevant for many. Providers must all listen to the RAC music being played today, understand the flow of the melody, the growth of new stanza’s and employ those who can ‘enjoy’ the new music form.

Musical Conclusion

Most often the articles I have written here have been meant to convey some new information or perhaps new way of seeing that which is widely known regarding the RAC program. It is a serious endeavor for CMS and should be taken very seriously by all providers, but the choice to ‘change the channel’ or not listen to this form of payer music is not optional. You can dislike the music, but you best get the point of the lyrics.

In conclusion, I love Jazz and the Jazz Festival here in New Orleans; I love the city, the people, the food, the sounds….. all of it……interesting note however , one of the closing acts this year is not known for their Jazz music, rather a form I do not know or enjoy over much….. it seems fitting to me that they are included and the crowds will be huge for them………Pearl Jam………..hmmm not consistent with the original theme 41 years ago I imagine…….none the less timely and worth listening to for many.

Pat Dear, eduTrax CEO

New Orleans

May 1, 2010