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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

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

slide2

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
slide3

FY 2009 Outreach Presentations

Circle = State Outreach Sessions

Square = National Presentations

Triangle = Local Presentations (Green = Regional)

slide4

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)
slide5

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)
slide6

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

slide7

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

what about rebilling
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
appeal when necessary
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
slide10

CMS Contact Information

  • CMS RAC Website: www.cms.hhs.gov/RAC
  • CMS RAC Email: RAC@cms.hhs.gov
slide12

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.

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slide13

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.

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