General Compliance Question of the Week
Archive
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January 23, 2012
Question:
What events or activities could lead to a recovery auditor blackout (transition) period?
Answer:
There will be a Medicare fee-for-service recovery auditor blackout period whenever a fiscal intermediary, carrier or MAC transitions to a new contractor. The length of the blackout period will vary dependent on each situation and will be communicated to the affected providers.
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January 16, 2012
Question:
Will Code N432 appear on the remittance advice for recovery audit contractor (RAC) adjusted claims?
Answer:
The Centers for Medicare & Medicaid Services (CMS) created code N432 to identify RAC-adjusted claims, but CMS states that it believes the code is being superseded in some of the systems by code N469 which is the Section 935 Limitation on Recoupment code. It is working to correct this problem in the system. Providers will receive demand letters for all RAC-adjusted claims. These letters will allow providers to keep track of RAC adjustments versus all other claims processing adjustments.
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January 9, 2012
Question:
How long does a provider have to submit medical records after receiving the request from a recovery auditor?
Answer:
Providers must respond within 45 days to a RAC request for medical records. Providers may request an extension at any time prior to the 45th day by contacting the contractor.
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January 2, 2012
Question:
Will the recovery auditors appeal process mirror those of the regular Medicare appeal process?
Answer:
The Medicare appeals process will remain the same for physicians under Part B and Part A non-inpatient claims. The only difference under Part A is for the inpatient hospital claims under the prospective payment system (PPS). In the current appeals process, the first level appeal will go to the Quality Improvement Organization (QIO); however, the RAC appeals will go to the fiscal intermediary that processed the claim.
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December 26, 2011
Question:
Are providers required to submit all the suggested documentation (including physician queries) identified in the Additional Documentation Request Letter they receive from Recovery Auditors?
Answer:
CMS requires that providers include the appropriate documents that justify the services billed. This may require that a provider include the entire medical record including physician queries.
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December 19, 2011
Question:
I have been hearing that RACs will be doing a new kind of review? What is this about?
Answer:
It is one of the new demonstration projects that the Centers for Medicare & Medicaid Services plan to conduct in 2012. Under this demonstration, recovery audit contractors (RACs) will review, prior to payment, certain types of claims that have shown high rates of improper payments. The prepayment review demonstration will test an alternative to the traditional “pay-and- chase” method of tracking down improper claims after Medicare pays them.
Seven states with large numbers of fraud- and error-prone providers will be subject to the prepayment reviews, including California, Florida, Illinois, Louisiana, Michigan, New York, and Texas. In addition, four states with high volumes of short inpatient stays will fall under the demonstration’s prepayment review, including Ohio, Pennsylvania, Missouri, and North Carolina.
To establish the pre-payment reviews, CMS intends to use numerous data sources and refer certain types of claims to RACs for review. According to CMS, “payment determinations will be made following the same processes with which providers are familiar.” Providers will continue to follow the appeal process established by the RACs for the post-payment reviews.
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December 12, 2011
Question:
Do RACs review evaluation and management services on physician claims under Part B?
Answer:
Yes, the review of all evaluation and management (E & M) services will be allowed under the RAC program. The review of duplicate claims or E & M services that should be included in a global surgery were available for review during the RAC demonstration and will continue to be available for review. The review of the level of the visit of some E & M services was not included in the RAC demonstration.
The Centers for Medicare & Medicaid Services state that it will work closely with the American Medical Association and the physician community prior to any reviews being completed regarding the level of the visit and will provide notice to the physician community before the RACs are allowed to begin reviews of E&M services and the level of the visit.
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December 5, 2011
Question:
Does Connolly Consulting (the recovery audit contractor for region C) accept electronic submission of medical documentation?
Answer:
According to the Centers for Medicare & Medicaid Services, Connolly is evaluating participating in its electronic submission of medical documentation (esMD) program and should have a more firm decision regarding participating shortly.
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November 28, 2011
Question:
Do providers have the option to instruct the RACs to pay health information handlers (HIH) directly for photocopying payments when using Electronic Submission of Medical Documentation (esMD)?
Answer:
Yes. Chapter 3 of the Medicare Program Integrity Manual (section 3.2.3.6) states that RACs must honor all requests from providers to issue photocopying payments to HIHs. They should gather from the provider all necessary information, such as, the HIH's name, phone number and bank routing number, etc.
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November 21, 2011
Question:
When will the Medicaid RAC program get started?
Answer:
The Medicaid recovery audit contractor (RAC) program will take effect on January 1, 2012. As required by federal statute, these RACs will review Medicaid claims to identify improper payments, which include over- and underpayments. For the final rule, go to http://www.gpo.gov/fdsys/pkg/FR-2011-09-16/html/2011-23695.htm.
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November 14, 2011
Question:
How exactly do the overpayments that RACs go after occur?
Answer:
According to the Centers for Medicare & Medicaid Services, the following are the primary reasons that overpayments occur:
- Duplicate submission of the same service or claim;
- Payment to the incorrect payee;
- Payment for excluded or medically unnecessary services; or
- A pattern of furnishing and billing for excessive or non-covered services.
CMS has published a useful fact sheet on overpayments, which can be found at https://www.cms.gov/MLNProducts/downloads/OverpaymentBrochure508-09.pdf.
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November 7, 2011
Question:
If I am participating in a CMS demonstration, are my claims exempt from reviews by recovery auditors?
Answer:
The Centers for Medicare & Medicaid services does grant temporary exemptions from RAC review for some of its sponsored demonstrations but not all of them. The demonstration contractor or CMS will alert providers if their claims are exempt from RAC review during the demonstration. This alert can usually be found in the initial welcome letter. Questions can be directed to the contractor performing the demonstration.
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October 31, 2011
Question:
Do RACs review Medicare Advantage claims?
Answer:
Not at the moment but the Centers for Medicare & Medicaid Services did issue a proposed rule in December 2010 to expand recovery audit contractor (RAC) reviews of claims submitted to Medicare Advantage (MA) plans.
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October 24, 2011
Question:
I have heard something about patient control numbers being used on the remittance advice. What is the purpose of these numbers?
Answer:
To ease payment posting, the Centers for Medicare & Medicaid Services instructed intermediaries to include patient control numbers on remittance advice when reporting recoupment of overpayments. The patient control numbers will replace the Medicare health insurance claim number, and this change is scheduled to be fully implemented by April.
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October 17, 2011
Question:
When will CMS mandate that all Medicare recovery auditors accept electronically submitted documentation?
Answer:
According to its web site, the Centers for Medicare & Medicaid Services plans to mandate that all Medicare RACs accept what’s called esMD transactions beginning in March of 2014. However, effective November 2011, three of the four recovery auditors will voluntarily accept esMD transactions and the four may do so in advance of March 2014 mandate.
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October 10, 2011
Question:
Will an overpayment be collected by RACs when a provider submits a claim containing an incorrect code but the mistake does not change the payment amount?
Answer:
No, this will not be considered an improper payment.
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October 3, 2011
Question:
I understand that our RAC (Connolly) will be auditing for non-routine medical supplies and home health consolidated billing. How are these paid, and can you provide a resource related to the billing guidelines on this?
Answer:
Under the prospective payment system (PPS), a home health agency must bill for all home health services, which include nursing and therapy services, except durable medical equipment (DME). The law requires that all home health services paid on a cost basis be included in the PPS rate, which includes nursing and therapy services, routine and nonroutine medical supplies, home health aide and medical social services.
For more see Chapters 10 and 20 of the Medicare Claims Processing Manual at http://www.cms.gov/manuals/downloads/clm104c10.pdf and http://www.cms.gov/manuals/downloads/clm104c20.pdf.
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September 26, 2011
Question:
If I receive a demand letter from a RAC because a service didn’t meet Medicare’s medical necessity criteria for an inpatient level of care, may I submit an outpatient claim for the service?
Answer:
Providers can re-bill for Inpatient Part B services, also known as ancillary services, but only for the services on the list in the Medicare Benefit Policy Manual. (See Section 10 in Chapter 6, which is available at http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf). Rebilling for any service will only be allowed if all claim-processing rules and claim-timeliness rules are met. There are no exceptions to the rules in the national program. Normal timely filing rules can be found in the Medicare Claims Processing Manual in Chapter 1, Section 70 at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
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September 19, 2011
Question:
Is it the RACs that will send demand letters when overpayments are found in Medicare claims?
Answer:
Until January 3, 2012, the answer to your question is yes. But beginning January 3, when recovery auditors (the new name for RACs) identify improper payments, they will issue a claim adjustment to the appropriate Medicare administrative contractor (MAC), which will then issue an automated demand letter for any overpayment.
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September 12, 2011
Question:
How will Medicare’s new bundled payment initiative affect RAC reviews?
Answer:
It’s too soon to tell whether and how the BPI will affect recovery audit contractor reviews.
Clearly, the BPI represents a significant step toward cost containment and improving quality of care for the Medicare program, and no one can argue with those goals. However, there are some questions to consider, which are listed below. Many more questions than the above will surface as the BPI unfolds, but it will be worthwhile to analyze how it may affect RAC activities in your organizations.
- Do you really understand the state (or quality) of your facility's current documentation as well as its coding and billing practices?
- Are there any known deficiencies that will be exposed during participation in the BPI? For example, if your facility struggles with documentation to support accurate MS-DRG assignment, will your organization be "held harmless" from exposure to improper payments if compliance violations are revealed?
- Do you understand the current state (or quality) of documentation, coding and billing practices of the doctors and suppliers that will be part of your team? Will they also be held harmless from exposure to improper payments if compliance violations for their services are discovered?
- Will your RAC coordinators and internal auditors be required to participate in this process? If so, what might be the impact on current compliance activities and workloads?
- And, finally, will the BPI require less emphasis or more emphasis on coding? Will providers still be required to report exact codes to describe the care provided or are alternative reporting mechanisms on the horizon? What, if any, effect will that have on the future of RAC evaluations?
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September 5, 2011
Question:
How many records can RACs request from small hospitals?
Answer:
Effective August 22, recovery audit contractors (RACs) can ask for up to 35 records every 45 days from providers that bill fewer than 27,200 claims. This is an increase for those providers that now are limited to 34 additional documentation requests or fewer because of the relatively small number of claims they bill. The maximum number of requests of 300 every 45 days remains unchanged since its implementation Nov. 2, 2010.
The Centers for Medicare & Medicaid Services just announced this update, which can be found at www.cms.gov/rac or http://www.aha.org/aha/content/2011/pdf/11racadrlimits.pdf.
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August 29, 2011
Question:
My question relates to documentation and RAC reviews. If physician supervision is defined as the physician being present in the building with no uninterruptable concurrent duties, how do we document physician availability retrospectively?
Answer:
According to the Centers for Medicare & Medicaid Services, documentation should include an acknowledgement in the patient record of the physician providing the supervision was on the hospital campus and immediately available to furnish assistance and direction during the entire procedure.
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August 22, 2011
Question:
Have the Medicaid RACs started their reviews yet?
Answer:
The Centers for Medicare & Medicaid Services still has not issued a final rule related to the Medicaid RAC program. Rumor has it that this will be issued later in 2011 as will a new implementation deadline for the states. However, work on implementation is progressing in all states.
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August 15, 2011
Question:
Can recovery audit contractors (RAC) do a medical necessity review on a claim that they originally reviewed for DRG validation?
Answer:
Beginning November 1, 2010 if the RAC has already requested documentation and issued a review results letter to the provider for a DRG Validation, the RAC will 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 also conduct both reviews simultaneously. Each additional documentation request (ADR) is subject to the same review timeframes and counts toward the provider's ADR limit.
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August 8, 2011
Question:
We received a demand letter from a RAC because a service didn't meet Medicare's medical necessity criteria for an inpatient level of service. Can we re-bill all the services on an outpatient claim?
Answer:
According to the Centers for Medicare & Medicaid Services, providers may re-bill for inpatient Part B ancillary services but only for the services on the list in the Medicare Benefit Policy Manual that can be found in Chapter 6, Section 10: http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf. Rebilling for any service will only be allowed if all claim-processing rules and claim-timeliness rules are met. There are no exceptions to the rules in the national program. Normal timely filing rules can be found in the Medicare Claims Processing Manual, Chapter 1, Section 70 at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
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August 1, 2011
Question:
I have been told that RACs are auditing claims for durable medical equipment (DME) rentals, and frankly I am confused about how to bill for them. Can you provide me with a source to educate me and my staff?
Answer:
The recovery audit contractors (RACS) have, in fact, been identifying overpayments associated with DMEPOS suppliers billing multiple rentals for the same equipment within the same month.
According to Medicare guidelines, payment for rentals for certain DME is made on a monthly basis. Within a single month, only one rental payment may be paid for the same item; the billing of additional rentals for the same item within the same overlapping time period represents an overpayment.
For more information, go to the Medicare Claims Processing Manual, Chapter 20–Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 130.6, Billing for Oxygen and Oxygen Equipment, which can be found at https://www.cms.gov/manuals/downloads/clm104c20.pdf.
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July 25, 2011
Question:
Is there a difference in the number of records recovery audit contractors request from small rural hospitals and larger urban hospitals or are they the same number?
Answer:
From hospitals with DRG payments in excess of $100 million annually may receive RAC requests up to 500 records in a 45-day period. The standard cap is 300 records. In a letter to hospitals affected by this increase, the Centers for Medicare & Medicaid Services explained to affected hospitals that they “have the capability to address a larger number of additional documentation requests.”
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July 18, 2011
Question:
I recently went to the web site entitled "State Medicaid RACs At-A-Glance" but the only thing there is a map. What is its purpose?
Answer:
The Centers for Medicare & Medicaid Services says that it created the website at https://www.cms.gov/medicaidracs/home.aspx to fill multiple purposes. The site provides basic recovery audit contractor information to the public and interested stakeholders about each state’s RAC program. As states fully implement their programs and additional elements are added to the site in the future, it will help states to monitor the performance of their own RAC programs and find information on other states’ programs that may assist them.
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July 11, 2011
Question:
What is the role of state Medicaid RACs?
Answer:
By law, Medicaid recovery audit contractors are tasked with identifying and recovering Medicaid overpayments and identifying underpayments. As an initial step for establishing their RAC programs, jurisdictions are expected to submit a Medicaid state plan amendment (SPA) that addresses some of the essential elements of their RAC program.
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July 4, 2011
Question:
Will RACs be auditing Part D program claims?
Answer:
Yes, eventually. In preparation for that, the Centers for Medicare & Medicaid Services announced (at the end of May) that it has contracted with ACLR Strategic Business Solutions and expects to implement the Part D RAC program component during the third quarter of this year.
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June 27, 2011
Question:
When a provider receives a recovery auditor’s additional documentation request letter, are they required to submit all the suggested documentation?
Answer:
The Centers for Medicare & Medicaid Services does require that providers include the appropriate documents that justify the services billed. This may require that a provider include the entire medical record including physician queries.
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June 20, 2011
Question:
What is the success rate for providers appealing RAC denials?
Answer:
According to the American Hospital Association’s RACTrac survey, an average of 39 percent of the respondents had denials reversed during the discussion period. Of the claims that have completed the appeals process, 71 percent were overturned in favor of the provider.
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June 13, 2011
Question:
Have RACs started their reviews in children’s hospitals?
Answer:
No, most RAC activities continue to occur in general medical and surgical acute care hospitals with critical access hospitals fairly far behind. Audits of the following types of hospitals are minimal at the moment: long-term acute care, inpatient rehabilitation, psychiatric, children’s, and “other” types (such as cancer and other specialty hospitals, etc.).
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June 6, 2011
Question:
Can we (providers) contact CMS if our RAC does not answer a question we posed?
Answer:
According to the Centers for Medicare & Medicaid Services, providers can contact it at RAC at cms.hhs.gov.
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May 30, 2011
Question:
Will RACs review evaluation and management (E&M) services on physician claims under Part B?
Answer:
Yes, according to the Centers for Medicare & Medicaid Services, the review of all E&M services will be allowed under the RAC program. The review of duplicate claims or E&M services that should be included in a global surgery were available for review during the RAC demonstration and will continue to be available for review. The review of the level of the visit of some E&M services was not included in the RAC demonstration. CMS states that it will work closely with the American Medical Association and the physician community prior to any reviews being completed regarding the level of the visit and will provide notice to the physician community before the RACs are allowed to begin reviews of E&M services and the level of the visit.
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May 23, 2011
Question:
Under what circumstances can a RAC make a finding that an overpayment or underpayment exists without requesting medical records?
Answer:
According to the Centers for Medicare & Medicaid Services, RACs may use automated review (where NO medical record is involved in the review) ONLY in situations where there is certainty that the claim contains an overpayment. To use automated review, there must be a “clear policy” that serves as the basis for the overpayment. “Clear policy” means a statute, regulation, national coverage determination, coverage provision in an interpretive manual, or local coverage determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment. Other options are that the automated review must be based on a medically unbelievable service or occur when no timely response is received in response to a medical record request letter.
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May 16, 2011
Question:
I am participating in a CMS demonstration. Are my claims exempt from RAC review?
Answer:
At times CMS does grant temporary exemptions from RAC review for CMS-sponsored demonstrations. However, all demonstrations do not get an exemption. The demonstration contractor or CMS will alert providers if their claims are exempt from RAC review during the demonstration. This alert can usually be found in the initial welcome letter. Questions can be directed to the contractor performing the demonstration.
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May 9, 2011
Question:
Last week you provided information about the number of medical records that RACs could request for hospitals with a $100-million threshold. What’s included in reaching the threshold?
Answer:
To determine the $100-million threshold, the Centers for Medicare & Medicaid Services counts hospitals' diagnosis-related group payments minus additional payments for outliers, disproportionate share hospitals, and direct and indirect graduate medical education. In a recent letter to hospitals subject to the new cap, CMS claims facilities with DRG payments in excess of $100 million "have the capability to address a larger number of additional documentation requests." The American Hospital Association has expressed concern to CMS over the significant increase in administrative burden for hospitals impacted by the new policy, which the association estimates will affect 87 hospitals.
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May 2, 2011
Question:
Are RAC record requests based on the profitability of the hospital?
Answer:
In the case of hospitals with more than $100 million in annual Medicare payments, recovery audit contractors can request up to 500 records within a 45-day period. This is a recently revised policy, up from 300 records.
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April 25, 2011
Question:
I know that lack of medical necessity is the biggest problem that RACs are finding during their audits. What can providers do to ensure this is present on claims?
Answer:
According to the Centers for Medicare & Medicaid Services (CMS), medical-necessity denials impact multiple codes but no coding trends were identified. Medicare contractors denied these claims because the medical documentation submitted did not:
- Support the diagnosis;
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Justify the treatment or procedures;
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Document the course of care;
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Identify treatment or diagnostic test results; and
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Promote continuity of care among healthcare providers.
One thing providers may do to justify Medicare claims payment is to make sure that the medical record contains sufficient documentation to demonstrate that the patient’s signs and symptoms were severe enough to require inpatient hospital medical care.
Also, physicians should document any pre-existing medical problems or extenuating circumstances that make the beneficiary’s admission medically necessary. In addition to the severity of the signs and symptoms exhibited (already mentioned above), physicians also should consider the medical predictability of an adverse happening to the patient, the need for diagnostic studies, and the availability of diagnostic procedures at the time and location where the patient presents.
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April 18, 2011
Question:
Will CMS be implementing the RAC program for Medicares Part C and D?
Answer:
In a December 27, 2010, notice, the Centers for Medicare & Medicaid Services (CMS) did ask the public for comments about this. The Affordable Care Act (ACA) requires that CMS expand the recovery audit program to the Medicare Parts C and D programs. For details, go to http://edocket.access.gpo.gov/2010/2010-32498.htm.
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April 11, 2011
Question:
Are there RAC record request limits for physicians like there are for hospitals?
Answer:
According to a CMS document (http://www.cms.gov/RAC/Downloads/PhyADR.pdf), RAC record requests for physicians and other practitioners are limited to a 45-day period based on the provider's Medicare claims for the previous calendar year. RACs will use the records to validate billing practices and medical necessity for services provided to Medicare patients.
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April 4, 2011
Question:
Will RACs be participating in the upcoming project related to electronic submission of medical records?
Answer:
Currently, three of the four Medicare recovery audit contractors (regions A, B and D) will participate in the electronic submission of medical documentation two-year pilot project that begins July 2011. By September 2011, providers may begin submitting medical documentation in the esMD X12 (275 claims attachment) format. (Note that provider participation is completely voluntary.)
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March 28, 2011
Question:
To avoid RAC denials, should hospitals focus more on improving their coding practices?
Answer:
Incorrect coding is one of the errors that recovery audit contractors are uncovering, but there are also other issues, such as MS-DRG assignment and level of care setting (medical necessity of an inpatient versus outpatient setting); inappropriate billing for non-covered services; and double billing. Improvements in all of these areas can reduce claims denials on all fronts.
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March 21, 2011
Question:
There seem to be a variety of contractors doing audits on provider records. Are they all looking for different types of things?
Answer:
You are correct that there are many types of contractors now at work on Medicare claims. Here’s the list so far:
• Comprehensive error rate testing (CERT) program contractors issue reports about high-risk payment MS-DRGs.
• Medicare fiscal intermediary (FI) and administrative contractors (MACs) conduct pre-bill and retrospective medical reviews for payment recoupment.
• Recovery audit contractors (RAC) conduct retrospective audits for payment recoupment.
• The TMF Health Quality Institute releases high-risk payment MS-DRGs through the Program for Evaluating Payment Patterns Electronic Report (PEPPER).
• Program safeguard contractors (PSC) and zone program integrity contractors (ZPIC) recoup payment for errors related to fraudulent billing patterns.
You may have noticed that the one word they have in common is payment.” In one way or another, they are all recouping payments.
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March 14, 2011
Question:
Does the new esMD have anything to do with RAC documentation submission?
Answer:
esMD stands for electronic submission of medical documentation, a new mechanism providers can use to respond to documentation requests from Medicare audit contractors in addition to other contractors, including Medicare administrative contractors (MACs). In July, a two-year pilot project on the esMD will begin. For more on this, go to http://www.cms.gov/ESMD.
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March 7, 2011
Question:
When will the Medicaid RACs start their reviews?
Answer:
These audits probably won’t start for a while since there are still many states that have not yet submitted their Medicaid recovery audit contractor (RAC) program plans to the Centers for Medicare & Medicaid Services. Although the original deadline for this requirement was April 1, 2011, that recently changed.
The Centers for Medicare & Medicaid Services has delayed the proposed April 1 deadline for states to implement their Medicaid Recovery Audit Contractor programs, according to a recent CMS bulletin.
In a February 1 letter to state Medicaid directors, CMS states, "Out of consideration for state operational issues and to ensure states comply with the provisions of the final rule, we have determined that states will not be required to implement their RAC programs by the proposed implementation date of April 1, 2011." CMS will set a new implementation date when it releases a final rule later this year.
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February 28, 2011
Question:
When will states begin implementing their Medicaid recovery audit contractor programs?
Answer:
The Centers for Medicare & Medicaid Services (CMS) has granted states a reprieve on establishing programs to contract with RACs to audit payments to Medicaid providers. They will not be required to implement their RAC programs by April 1, 2011, as CMS originally proposed. Instead, when CMS publishes the final rule, perhaps later this year, it will indicate the new implementation deadline.
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February 21, 2011
Question:
If I receive a demand letter from a RAC because a service didn’t meet Medicare’s medical necessity criteria for an inpatient level of service, can we re-bill all the services on an outpatient claim?
Answer:
Providers can re-bill for inpatient Part B ancillary services but only for those listed in the Medicare Benefit Policy Manual (http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf). Rebilling for any service will only be allowed if all claim-processing and -timeliness rules are met. There are no exceptions to the rules in the national program, according to the Centers for Medicare & Medicaid Services. The time limit for re-billing claims is 15 to 27 months from the date of service. These normal timely filing rules can be found in the Medicare Claims Processing Manual (Chapter 1, Section 70) at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
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February 14, 2011
Question:
Some of our hospital staff members are concerned about the screening criteria, such as InterQual, used by RACs and other Medicare contractors. Is this all they use to analyze medical documentation to determine whether inpatient hospital claims are medically necessary?
Answer:
According to the Centers for Medicare & Medicaid Services, RACs and other contractors also use Medicare coverage guidelines as well as admission, invasive procedure, and well-accepted practice guidelines.
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February 7, 2011
Question:
Are RACs investigating anything related to inpatient admissions?
Answer:
At least one recovery audit contractor (RAC) (Connolly) is reviewing documentation to validate the medical necessity of short-stay, uncomplicated DRGs. Its focus is to ensure that the documentation supports the codes that have been assigned.
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January 31, 2011
Question:
What is the difference between the RAC discussion period and the rebuttal-and-redetermination process?
Answer:
The discussion period offers the opportunity for providers to provide additional information to the recovery audit contractor (RAC) to indicate why recoupment should not be initiated, according to the Centers for Medicare & Medicaid Services. It also offers the opportunity for the RAC to explain the rationale for the overpayment decision. After reviewing the additional documentation submitted, the RAC could decide to reverse their decision. If so, the RAC will send a letter to the provider detailing the outcome of the discussion period.
The rebuttal process allows the provider the opportunity to provide a statement and accompanying evidence indicating why the overpayment action will cause a financial hardship and should not take place. It is not intended to review supporting medical documentation nor disagreement with the overpayment decision. A rebuttal should not duplicate the redetermination process. You will always contact the contractor/MAC for this option.
A redetermination is the first level of appeal. Providers may request redeterminations when they are dissatisfied with the overpayment decision. A redetermination must be submitted within 30 days to prevent offset on day 41. You will always contact your Medicare contractor for this option.
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January 24, 2011
Question:
What happens if the recovery auditor does not meet the 60-day requirement for issuing a notice of determination?
Answer:
The recovery auditors have 60 days from receipt of the medical records to make a determination and issue a written notice of that determination to providers. The 60-day requirement can be found in the Statement of Work used in the Recovery Audit Program. Lack of adherence to the 60-day requirement of notification does not negate the improper payment finding or the recoupment of the improper payment by the Centers for Medicare & Medicaid Services (CMS). Lack of adherence to the 60-day requirement is a performance issue between CMS and the recovery auditor.
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January 17, 2011
Question:
Will Medicaid RACs replace the Medicaid integrity contractors (MICs)?
Answer:
No, Medicaid RACs are just another auditor added to the mix. Like their Medicare counterparts, Medicaid RACs will audit claims, identify underpayments, and identify and collect overpayments.
In a proposed rule, the Centers for Medicare and Medicaid Services (CMS) explained its plans for expanding the RAC program to Medicaid. The rule stems from the Affordable Care Act’s broad strategy to clean up waste, fraud, and abuse in health care. According to the Act, States had to establish their Medicaid RAC programs by December 31, 2010, and must have them fully implemented by April 1, 2011.