RAC Program Slide Presentation

1 Recovery Audit Contractors (RACs) and Medicare The Who, What, When, Where, How and Why?2 Agenda • What is a RAC? • Will the RACs affect me? • Why RACs? • What does a RAC do? • What are the providers’ options? • What can providers do to get ready?3 What is a RAC? The RAC Program Mission • The RACs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments: • Providers can avoid submitting claims that do not comply with Medicare rules • CMS can lower its error rate • Taxpayers and future Medicare beneficiaries are protected4 Will the RACs affect me? • Yes, if you bill fee-for-service programs, your claims will be subject to review by the RACs • If so, when? • The expansion schedule can be viewed at www.cms.hhs.gov/rac5 RAC Legislation • Medicare Modernization Act, Section 306 Required the three year RAC demonstration • Tax Relief and Healthcare Act of 2006, Section 302 Requires a permanent and nationwide RAC program by no later than 2010 Both Statutes gave CMS the authority to pay the RACs on a contingency fee basis.6 What does a RAC do? The RAC Review Process • RACs review claims on a post-payment basis • RACs use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and CMS Manuals • Two types of review: Automated (no medical record needed) Complex (medical record required) • RACs will not be able to review claims paid prior to October 1, 2007 RACs will be able to look back three years from the date the claim was paid • RACs are required to employ a staff consisting of nurses, therapists, certified coders, and a physician CMD7 The Collection Process • Same as for Carrier, FI and MAC identified overpayments (except the demand letter comes from the RAC) Carriers, FIs and MACs issue Remittance Advice • Remark Code N432: Adjustment Based on Recovery Audit Carrier/FI/MAC recoups by offset unless provider has submitted a check or a valid appeal8 What is different? • Demand letter is issued by the RAC • RAC will offer an opportunity for the provider to discuss the improper payment determination with the RAC (this is outside the normal appeal process) • Issues reviewed by the RAC will be approved by CMS prior to widespread review • Approved issues will be posted to a RAC website before widespread review9 What are providers’ options? If you agree with the RAC’s determination: • Pay by check • Allow recoupment from future payments • Request or apply for extended payment plan • Appeal Appeal Timeframes http://www.cms.hhs.gov/OrgMedFFSAppeals/Downloads/Appealsproce ssflowchartAB.pdf 935 MLN Matters http://www.cms.hhs.gov/MLNMatterArticles/downloads/MM6183.pdf10 Three Keys to Success • Minimize Provider Burden • Ensure Accuracy • Maximize Transparency11 Minimize Provider Burden • Limit the RAC “look back period” to three years Maximum look back date is October 1, 2007 • RACs will accept imaged medical records on CD/DVD (CMS requirements coming soon) • Limit the number of medical record requests12 Summary of Medical Record Limits (FY 2009) • Inpatient Hospital, IRF, SNF, Hospice 10% of the average monthly Medicare claims (max 200) per 45 days per NPI • Other Part A Billers (HH) 1% of the average monthly Medicare episodes of care (max 200) per 45 days per NPI • Physicians (including podiatrists, chiropractors) Sole Practitioner: 10 medical records per 45 days per NPI Partnership (2-5 individuals): 20 medical records per 45 days per NPI Group (6-15 individuals): 30 medical records per 45 days per NPI Large Group (16+ individuals): 50 medical records per 45 days per NPI • Other Part B Billers (DME, Lab, Outpatient Hospital) 1% of the average monthly Medicare claim lines (max 200) per NPI per 45 days13 Ensure Accuracy • Each RAC employs: Certified coders Nurses Therapists A physician CMD • CMS’ New Issue Review Board provides greater oversight • RAC Validation Contractor provides annual accuracy scores for each RAC • If a RAC loses at any level of appeal, the RAC must return its contingency fee14 Maximize Transparency • New issues are posted to the web • Vulnerabilities are posted to the web • RAC claim status website (2010) • Detailed Review Results Letter following all Complex Reviews15 What Can providers do to get Ready?16 Know where previous improper payments have been found • Look to see what improper payments were found by the RACs: Demonstration findings: www.cms.hhs.gov/rac Permanent RAC findings: will be listed on the RACs’ websites • Look to see what improper payments have been found in OIG and CERT reports OIG reports: www.oig.hhs.gov/reports.html CERT reports: www.cms.hhs.gov/cert17 Know if you are submitting claims with improper payments • Conduct an internal assessment to identify if you are in compliance with Medicare rules • Identify corrective actions to promote compliance • Appeal when necessary • Learn from past experiences18 Prepare to respond to RAC medical record requests • Tell your RAC the precise address and contact person they should use when sending Medical Record Request Letters Call RAC No later 1/1/2010: use RAC websites • When necessary, check on the status of your medical record (Did the RAC receive it?) Call RAC No later 1/1/2010: use RAC websites19 Appeal when necessary • The appeal process for RAC denials is the same as the appeal process for Carrier/FI/MAC denials • Do not confuse the “RAC Discussion Period” with the Appeals process • If you disagree with the RAC determination… • Do not stop with sending a discussion letter • File an appeal before the 120th day after the Demand letter20 Learn from past experiences • Keep track of denied claims • Look for patterns • Determine what corrective actions you need to take to avoid improper payments21 Contacts • RAC Website: www.cms.hhs.gov/RAC • RAC Email: RAC@cms.hhs.gov