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CDR Marie Casey Scott Wakefield

CDR Marie Casey Scott Wakefield . RAC Program Update. 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

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CDR Marie Casey Scott Wakefield

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  1. CDR Marie CaseyScott Wakefield RAC Program Update

  2. 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 protected

  3. RAC Legislation • Medicare Modernization Act, Section 306 • Required the 3-year RAC demonstration • Tax Relief and Healthcare Act of 2006, Section 302 • Requires a permanent and nationwide RAC program by January 1, 2010 • Both of these statutes gave CMS the authority to pay the RACs on a contingency fee basis

  4. D A B C RAC Regions

  5. What is the Current Status of the Permanent RAC Program? • Provider outreach has occurred in every state • All RACs have Medicare claims data • All states are eligible for review • All RACs have posted new issues on their website • Mass adjustment process implemented July 2010

  6. What is the Current Status of the Permanent RAC Program? • Release of several education articles (MLN and Quarterly newsletter) based on RAC identified vulnerabilities • Post Quarterly RAC Data beginning in 2011 • Demanded, Underpayment, Collected Amounts • Top 3 reasons for Additional Documentation Requests (ADRs) • Number of ADRs requested • Publish Annual Report to Congress

  7. How do RACs Select Claims for Review?

  8. CMS RAC Review Strategy • DRG Validation- complex review (fall 2009) • Complex Review for coding errors (fall 2009) • Automated Review- Black & White Issues (early 2009) • DME Medical Necessity Reviews – complex review (calendar year 2010) • Medical Necessity Reviews-complex review (calendar year 2010)

  9. 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)

  10. Sample New Issues • Pharmacy Supply and Dispensing Fees • Wheelchair Bundling • Urological Bundling • Blood Transfusions • IV-Hydration • Neulasta (Pegfilgrastim) • Once in a Lifetime Procedures • Untimed Codes • Clinical Social Worker (CSW) Services • DRG Validation (various)

  11. Example 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

  12. Example New Issue Posting 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

  13. Major Findings – Closing the Loop • RACs post major findings to their websites • CMS publishes information on RAC major findings in the Annual Report to Congress • RACs share vulnerabilities internally and with all Medicare Contractors who will implement appropriate corrective actions

  14. RAC ContactInformation • Region A: Diversified Collection Services (DCS) • www.dcsrac.com • info@dcsrac.com • Region B: CGI Federal • http://racb.cgi.com • racb@cgi.com • Region C: Connolly Healthcare • www.connollyhealthcare.com/RAC • RACinfo@connollyhealthcare.com • Region D: HealthDataInsights (HDI) • https://racinfo.healthdatainsights.com • racinfo@emailhdi.com

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

  16. Thank you for inviting us!

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