Author Archive for: The RAC Report
Q&A: Interacting with a RAC
November 26th, 2008 
Q: One of the challenges that many providers have faced is the inability to sufficiently interface (e.g., to see a human, get a return phone call, or otherwise interact in a personalized manner) with a RAC with respect to questions, concerns or confusion that occasionally arise. Will the permanent RACs be more welcoming of human interaction?
A: Yes. When you contact the RAC, they are required to return a phone call within one business day. In the permanent program, if a provider calls during the second period—or at any time—to discuss a determination, the RAC is required to let the provider speak to the medical director or the person that reviewed the claim.
Editor’s note: This Q&A was adapted from the November 13 RAC Open Door Forum. A CMS representative answered this question.
Tip: Review OIG publications for hints
November 26th, 2008
The permanent RAC program may be on hold for a short time. However, this doesn’t mean you should stop preparing for RACs. Using the 100 days to review and study the Office of Inspector General (OIG) reports and work plans is one way to internally identify like behaviors that may put you at risk for a RAC audit, suggests William L Malm, ND, partner at Health Revenue Integrity Services in Westlake, OH. The OIG has clearly outlined much of what the RACs are looking for in them, he notes.
So while you have this brief reprieve, get your facility in line by studying the OIG publications, Malm says. Taking the time to read and understand them can help you avoid recoupments.
Editor’s note: To view the latest OIG Work Plan, click here. To see a list of OIG reports, click here.
News: CMS reports decrease in improper payments
November 26th, 2008
Improper payments for Medicare fee-for-service (FFS) decreased from 3.9% to 3.6% in fiscal year (FY) 2007, CMS announced in a November 17 press release. The change represents approximately $400 million.
For the first time CMS also reported Medicare Advantage improper payment rates for calendar year 2006 and national composite error rates for Medicaid and for the State Children’s Health Insurance Program (SCHIP) for 2007. CMS made $6.8 billion (or 10.6%) in improper payments for Medicare Advantage during calendar year 2006. The Medicaid composite error rate is 10.5% ($32.7 billion, the federal share being $18.6 billion). The SCHIP composite error rate is 14.7% ($1.2 billion, the federal share being $0.8 billion).
The improper payments do not necessarily reflect fraud, according to the press release. Incorrect coding or medically unnecessary procedures account for many of the improper payments. Inadequate documentation is a common problem leading to Medicaid and SCHIP improper payments.
CMS’ has gone to great efforts to reduce payment errors; the Medicare FFS error rate has declined more than 10% since 1996, according to the press release.
"We are using the most effective information-gathering tools available to help us identify and eliminate improper payments in our efforts to protect the integrity of CMS programs," Kerry Weems, CMS acting administrator said in the press release.
To read the press release, click here.
Update: RAC medical record request limits
November 26th, 2008
It looks like healthcare providers can count on the RAC medical record request limitations announced October 30—at least for now.
CMS reserves the right to review the request limits, but currently has no plan or set timeline as to when an adjustment may occur, CMS representative Lt. Terrence Lew, said during the November 13 RAC Open Door Forum.
“We could conceivably adjust the limits annually. But beyond that, we haven’t really set a schedule for adjusting them,” Lew said.
Lew also confirmed that CMS has spoken to the American Hospital Association as well as the American Medical Association regarding the medical record request limit.
Update: RAC medical record request limits
November 26th, 2008
It looks like healthcare providers can count on the RAC medical record request limitations announced October 30—at least for now.
CMS reserves the right to review the request limits, but currently has no plan or set timeline as to when an adjustment may occur, CMS representative Lt. Terrence Lew, said during the November 13 RAC Open Door Forum.
“We could conceivably adjust the limits annually. But beyond that, we haven’t really set a schedule for adjusting them,” Lew said.
Lew also confirmed that CMS has spoken to the American Hospital Association as well as the American Medical Association regarding the medical record request limit.
For more information on the medical request limits, click here.
CMS RAC Open Door forum update
November 13th, 2008
During the November 12 RAC Open Door Forum for Part A providers, CMS announced its intent to do the following with the permanent RAC program:
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Minimize hassles for providers. This includes limiting the volume of medical records RACs may request, and allowing RACs to look back three years instead of four.In addition, CMS is requiring RACs accept imaged records on CD/DVD.
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Maximize transparency. Among other steps, CMS has made it mandatory for RACS to have a Web site showing status of every claim by 2010, as well as send out detailed letters to providers reviewing results. The Web sites will also post types of audits as well as vulnerabilities.
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Maximize accuracy. CMS has required RACs to have medical directors and certified coders (i.e., coders with CCF, CCA, CCSP, CPC, CPC-H, or CRNC credentials).
In addition, during the call, CMS recommended providers take certain steps to prepare for the permanent RAC program. Suggested steps include the following:
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Review and understand all documents from the RAC demonstration
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Review all findings by permanent RACs once the program begins
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Review all current OIG reports at www.oig.hhs.gov/reports.asp
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Review the information on the CMS Comprehensive Error Rate Testing (CERT) Web site at www.cms.hhs.gov/cert
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Put in place an internal audit program
CMS will be holding a special RAC Open Door Forum for Part B providers Thursday, November 13, at 2:00 p.m., ET. If you missed the similar call for Part A providers November 12, a recording will be available on the CMS Web site beginning November 19.
Tip: If you plan on dialing in for the RAC Open Door Forum call for Part B providers on November 13, do so early. You may dial in as early as 1:45 p.m. ET. The November 12 call reached maximum capacity well before 2:00 p.m. ET.
Quote of the week
November 13th, 2008
“The bottom line is, from where I sit, RACs are here to stay and this little hiccup, even if lasts 90 days, will be an insignificant and long-forgotten bump in the road by next year.”
—Kenneth R. Rubin, MD, MA, MSHCM, FACEP, principal, ExpertAppeals.com
Update: CMS delays RAC permanent program
November 13th, 2008
By now you know that CMS announced a delay in the Medicare RAC permanent program. But what you may not yet know is that the delay is a result of protests filed with the Government Accountability Office (GAO) by two unsuccessful RAC program bidders (PRG-Schultz USA, Inc., and Viant, Inc.).
The GAO has up to 100 days to make a decision regarding the protests. It has scheduled February 9, 2009 protest hearing for Viant and a February 11 hearing for PRG-Schultz USA, according to the GAO Web site. In the meantime, CMS has announced a delay for all educational and outreach programs scheduled through December.
Despite the delay in the process, Joseph Zebrowitz, MD, executive vice president of Executive Health Resources in Newtown Square, PA, warns facilities not to change anything in terms of preparing for a RAC visit. "Basically, this is infighting amongst CMS potential contractors who are upset that they were not awarded the RAC contract," Zebrowitz says. "[CMS] just can not start when the contractors are in doubt. Once they resolve these complaints, they will start up."
For more information, visit the CMS Web site.
Dig out your calculators: CMS announces RAC medical record request limitations
November 13th, 2008
On October 30, CMS announced limitations on the number of medical records RACs could request for fiscal year 2009 on the CMS Web site.
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Inpatient hospitals, inpatient rehabilitation facilities, skilled nursing facilities and hospices. RACs may request up to 10% of the average monthly Medicare claims (maximum of 200) every 45 days.
The CMS Web site provides the following example:
A Major Medical Center has 12,000 Medicare paid claims in 2007
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12,000 claims divided by 12 (months in a year) = avg 1,000 paid claims/month
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1,000 paid claims/month x 10% = 100
Therefore, the limit a RAC may request from the medical center is 100 medical records per 45 days
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Outpatient hospitals, home health and other types of Medicare Part A billers. RACs may request 1% of the average monthly Medicare services (maximum of 200) ever 45 days.
The CMS Web site provides the following example:
A provider has 360,000 Medicare paid services in 2007
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360,000 services divided by 12 (months in a year) = avg 30,000 paid services/month
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30,000 paid services/month x 1% = 300
However, a RAC may request a maximum of 200 medical records per 45 days because it may not request more than 200 records per 45 days.
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Physicians. The number of records a RAC may request from a physician practice depends on the size of the practice. For example, a RAC may request a maximum of 10 records from a solo practitioner, whereas it may request a maximum of 50 records from a large group of more than 16 individuals.
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Other Medicare Part B billers (e.g., DMEs, labs). RACs may request 1% of the average monthly Medicare services (maximum of 200) ever 45 days.
For more information on the medical record request limitations, click here.
In the news: SSA seeks input on increasing efficiency of ALJ hearings
November 13th, 2008
The Social Security Administration is seeking comments on a proposed rule that will attempt to increase the case load and efficiency of Administrative Law Judge hearings, according to the November 10 Federal Register.
The significant backlog of hearings affects hospitals and other providers currently waiting to appeal denials from the RAC demonstration project.
“The number of cases awaiting a hearing has reached historic proportions, and efforts toward greater efficiency are critical to addressing this problem,” according to the Federal Register.
The government may have underestimated the impact that RACs would have on a federal level, according to Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital in Arcadia, CA. “I’m not sure how a system that was bogged down by a demonstration with three states and three auditors is going to handle 50 states with only four auditors,” she says.
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Inpatient hospitals, inpatient rehabilitation facilities, skilled nursing facilities and hospices. RACs may request up to 10% of the average monthly Medicare claims (maximum of 200) every 45 days.
The CMS Web site provides the following example:A Major Medical Center has 12,000 Medicare paid claims in 2007
-
Outpatient hospitals, home health and other types of Medicare Part A billers. RACs may request 1% of the average monthly Medicare services (maximum of 200) ever 45 days.
The CMS Web site provides the following example:A provider has 360,000 Medicare paid services in 2007
-
Physicians. The number of records a RAC may request from a physician practice depends on the size of the practice. For example, a RAC may request a maximum of 10 records from a solo practitioner, whereas it may request a maximum of 50 records from a large group of more than 16 individuals.
-
Other Medicare Part B billers (e.g., DMEs, labs). RACs may request 1% of the average monthly Medicare services (maximum of 200) ever 45 days.
In the news: SSA seeks input on increasing efficiency of ALJ hearings
November 13th, 2008
The Social Security Administration is seeking comments on a proposed rule that will attempt to increase the case load and efficiency of Administrative Law Judge hearings, according to the November 10 Federal Register.
The significant backlog of hearings affects hospitals and other providers currently waiting to appeal denials from the RAC demonstration project.
“The number of cases awaiting a hearing has reached historic proportions, and efforts toward greater efficiency are critical to addressing this problem,” according to the Federal Register.
The government may have underestimated the impact that RACs would have on a federal level, according to Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital in Arcadia, CA. “I’m not sure how a system that was bogged down by a demonstration with three states and three auditors is going to handle 50 states with only four auditors,” she says.
The comment period ends January 9, 2009. Click here to comment on the proposed rule.
DID YOU KNOW: Scoop on HDI
October 30th, 2008
HealthDataInsights (HDI), Inc. of Las Vegas, NV, the RAC selected by CMS to begin reviewing hospitals in Region D (initially Montana, Wyoming, North Dakota, South Dakota, Utah, and Arizona), had the most overpayment determinations of any RAC in the demonstration project with 239,205.
However, it also had the most overturned on appeals (11.5%), according to CMS numbers released here in September.
