RAC News
CMS Update
June 26, 2009
CMS is often asked about the phase-in strategy for RAC reviews. CMS has implemented a phase in strategy by review type. CMS' phase in strategy can be found in the downloads section on the recent updates page. CMS has not put a phase in strategy in place by provider type. All provider types are available for RAC review once provider outreach has occurred in the state. Any reviews completed by the RAC must have been first approved by CMS and posted to the RAC websites. The RAC websites can be found in the RAC contact information document in the downloads section below. CMS expects the first approved new issues to be posted in July 2009.
CMS is often asked about other claim types that may be affected by a full inpatient denial and if the RACs will deny other claim types associated with the inpatient stay, such as physician evaluation and management services. At this time the RAC will not automatically deny claims that are associated with a full inpatient denial. However, these claims may be reviewed individually and there may be a need to fully/partially adjust the claim based on the documentation submitted.
New RAC Nationwide Rollout Update
June 10, 2009
According to CMS, the first correspondence providers are to receive from a Recovery Audit Contractor (RAC) will most likely be an automated issue---a review that does not involve review of the medical record. “For example, a duplicate claim can be identified through the review of the claim data. The medical record is not necessary,” explained a CMS spokesperson.
The first letters are expected as early as late June or early July. CMS told This Week in Corporate Compliance on June 8, 2009 that “medical record requests will not occur until later in the summer” and that medical necessity reviews “are not expected until after January 1, 2010.” CMS also noted that “other complex medical review such as DRG validation and coding errors will begin later this summer.”
As for areas of review, CMS said it is currently in the process of approving areas of review. “The agency has not approved any issues yet,” said a CMS spokesperson. However, “upon approval, the new issues will be posted on the RAC websites.”
Marlene Robinson
Health Care Compliance Association
San Diego system fights RAC procedures
Jennifer Lubell
Posted: March 27, 2009 - 5:59 am EDT
A San Diego health system has filed a complaint in federal court, challenging procedures used by Medicare’s recovery audit contractors to reopen claims.
The controversial audit program pays incentive fees to third-party auditors of Medicare reimbursement. The suit, which was filed by two-hospital Palomar Pomerado Health against HHS, alleges that RAC contractor PRG-Schultz International unlawfully reopened a claim by Palomar during the CMS’ RAC demonstration project without showing “good cause” for the reopening as required by Medicare regulations.
Medicare regulations require that RAC contractors show “good cause” for reopening and reviewing claims between one and four years after payment. Atlanta-based PRG-Schultz, which administered RAC audits for California during the demonstration project, had a reputation for denying a large portion of the Medicare inpatient rehabilitation claims it reviewed in the state.
The lawsuit also alleges that the Medicare Appeals Council was incorrect in its 2008 ruling that administrative law judges do not have jurisdiction to decide whether a claim was reopened lawfully. The complaint was filed in U.S. District Court in San Diego with the support of the Fund for Access to Inpatient Rehabilitation or “FAIR” Fund, a legal defense fund made up primarily of inpatient rehabilitation hospitals and units. The CMS is in the process of implementing a permanent RAC program, in which PRG-Schultz is a subcontractor.
CMS reinstates RAC program after delay prompted by bid protests
Jennifer Lubell
Posted: February 6, 2009 - 6:30 pm EDT
The Recovery Audit Contractor Program is back in business, with a few key changes. The CMS announced that the parties involved in the protest of the award of the RAC contracts had reached a settlement, putting an end to the stop-work order issued last fall. The CMS “will now continue with the implementation of the RAC program,” according to a program update issued by the agency.
As part of the settlement, the two contractors that originally filed the protest will serve as subcontractors to two of the permanent RAC contractors. Specifically, PRG-Schultz International, in Atlanta, will serve as a subcontractor to HealthDataInsights, of Las Vegas, which will initially cover the states of Arizona, Montana, North Dakota, South Dakota, Utah and Wyoming. In addition, Viant Health Payment Solutions, headquartered in Naperville, Ill., will serve as a subcontractor to Connolly Consulting, of Wilton, Conn., which will conduct audits in Colorado, Florida, New Mexico and South Carolina. The controversial program had been suspended last November, when Viant and PRG-Schultz protested the contracts that had been awarded to four others.
CMS Announces Special Open Door Forums on Recovery Audit Contractors
March 27, 2009
The Centers for Medicare & Medicaid Services (CMS) recently announced that it will be hosting 2 Special Open Door Forums on the Medicare recovery audit contractor (RAC) program.
According to CMS, the purpose of the Special Open Door Forums is to introduce providers to the new RAC contractors and provide more information about the Medicare RAC program.
For Part A providers:
The Special Open Door Forum will take place from 2:00 p.m. - 3:30 p.m. (EST) on April 8, 2009. To participate in this Special Open Door Forum, one must call 1-800-837-1935 and reference conference ID 92490299. Beginning April 16, 2009, CMS will also post an audio recording and transcript of this Special Open Door Forum on the Special Open Door Forum page of the CMS website, which will be available for 30 days.
For Part B providers:
The Special Open Door Forum will take place from 2:00 p.m. - 3:30 p.m. (EST) on April 14, 2009. To participate in this Special Open Door Forum, one must call 1-800-837-1935 and reference conference ID 92489480. Beginning April 22, 2009, CMS will also post an audio recording of this Special Open Door Forum on the Special Open Door Forum page of the CMS website, which will be available for 30 days.
CMS suggests calling in early because capacity is limited for these Special Open Door Forums. CMS reports that one may begin calling into these forums as early as 1:45 p.m. (ET).
