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Recovery Audit Contractor (RAC) Program Review and Update

Recovery Audit Contractor (RAC) Program Review and Update. Narcessa Chesil Project Officer, RAC Region C Division of Recovery Audit Operations Centers for Medicare & Medicaid Services. What is the Current Status of the Permanent RAC Program?.

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Recovery Audit Contractor (RAC) Program Review and Update

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  1. Recovery Audit Contractor (RAC)Program Review and Update Narcessa Chesil Project Officer, RAC Region C Division of Recovery Audit Operations Centers for Medicare & Medicaid Services

  2. What is the Current Status of the Permanent RAC Program? • The Tax Relief and Health Care Act of 2006, Section 302, required a permanent and nationwide RAC program by January 1, 2010 • Provider outreach has occurred in every state • All RACs have data • All states are now eligible for review

  3. FY 2009 Outreach Presentations Circle = State Outreach Sessions Square = National Presentations Triangle = Local Presentations (Green = Regional)

  4. CMS RAC Review Phase-in Strategyas of 06/24/09 Earliest possible dates for reviews in yellow/green states Earliest possible dates for reviews in blue states • Automated Review- Black & White Issues (June 2009) • DRG Validation- complex review (Aug/Sep 2009) • Complex Review for coding errors (Aug/Sep 2009) • DME Medical Necessity Reviews – complex review (Fiscal year 2010) • Medical Necessity Reviews-complex review (Calendar year 2010) • Automated Review- Black & White Issues (August 2009) • DRG Validation- complex review (Oct/Nov 2009) • Complex Review for coding errors (Oct/Nov 2009) • DME Medical Necessity Reviews – complex review (Fiscal year 2010) • Medical Necessity Reviews-complex review (Calendar year 2010)

  5. Where are New Issues Posted? • Region A: Diversified Collection Services (DCS) • www.dcsrac.com (Provider Portal/Issues Under Review) • Region B: CGI Federal • http://racb.cgi.com (Issues) • Region C: Connolly Healthcare • www.connollyhealthcare.com/RAC (Approved Issues) • Region D: HealthDataInsights (HDI) • https://racinfo.healthdatainsights.com (New Issues)

  6. Some New Issues Pharmacy Supply and Dispensing Fees Wheelchair Bundling Urological Bundling Blood Transfusions Bronchoscopy Services IV-Hydration Neulasta (Pegfilgrastim) Once in a Lifetime Procedures Untimed Codes Clinical Social Worker (CSW) Services Knee Orthotic Bundling

  7. Example of A New Issue Posting Issue Name: Wheelchair Bundling Description: Bundling guidelines for wheelchair bases and options/accessories indicate certain procedure codes are part of other procedure codes and, as a result, are not separately payable. Provider Type Affected:    DME Date of Service: 10/01/2007 - Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: http://www.cms.hhs.gov/mcd/viewarticle_pdf.asp?article_id=20284&article_version=32&contractor_id=140

  8. What about Rebilling? • Providers can re-bill for Inpatient Part B services, also known as ancillary services, but only for the services listed in the Benefit Policy Manual. That list can be found at: http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf • Rebilling for any service will only be allowed if all claims processing and timeliness rules are met. The normal timely filing rules can be found at: http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf

  9. Appeal When Necessary • The appeals process for RAC denials is the same as the appeals process for Carrier/FI/MAC denials • Do not confuse the “RAC Discussion Period” with the appeals process • Appeals data from demonstration and going forward

  10. CMS Contact Information • CMS RAC Website: www.cms.hhs.gov/RAC • CMS RAC Email: RAC@cms.hhs.gov

  11. Questions?

  12. Questions: • Q. Please clarify the reason for discussion period and how the provider should include this in their process? • A. The RAC Auditors contact information will be on each demand letter and the provider would call them for discussion if there was clearly an error in the take back demand. • Q. Will interest begin at day 30 or day 41 from the date of the demand letter? • A. Interest will begin on day 30 • Q. What process does the provider use to rebill Part B Ancillary services following the denial of a Part A claim. • A. See Slide 8 – Remember : Provider cannot rebill until claim adjustment is made or I/P claim is paid back. 12

  13. Questions: • Q. Does CMS anticipate starting the complex reviews earlier than January 2010? • A. No • Q. Will CAH's be reimbursed for copying cost differently than PPS hospitals? • A. Yes, CAH’s will be reimbursed on their cost report. Copy cost is an allowable Medicare cost at .12 per copy. PPS hospitals will be reimbursed monthly. • Q. Can you confirm that all deductables and copays must be returned to the patient on claims identified for takeback? • A. Yes, the beneficiary will be notified after the claim has been recouped. 13

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