attack of the rac how to prepare and respond to rac audits
TRANSCRIPT
ATTACK of the RAC
How to prepare and How to prepare and respond to RAC auditsrespond to RAC audits
Overview
• Current Status
• How to Prepare– Education– RAC Response Team– Independent Audit– Communication
• How to Respond– Documentation– Rebuttal – Appeals Process
Current Status in Virginia
• Region C– Contractor: Connolly– Subcontractor: Viant
• MAC Delay- Medicare Part A
• Current Negotiations- Medicare Part B– 50 Day Countdown…
How to Prepare: Education
• Learn from colleagues, the Demonstration Project and other sources
– Medical necessity– Coding errors– RAC Status Documents (www.cms.gov/rac)– OIG Work Plan– Connolly’s Identified Issues
http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx
• Education for physicians and staff– Focus on areas of known weaknesses
Demonstration Results
How to Prepare:Independent Audit
• Self Disclosure– Important to work with legal counsel
• Legal obligations
• Benefits and Consequences
• Process for Voluntary Refunds
How to Prepare:RAC Response Team
• Develop a RAC Response Team Now– Include members from all areas of risk– On-going duties
• Team responsible for entire RAC process– Assessing areas of risk– Keeping track of all record requests– Implementing compliance strategies– Handling all RAC reviews and appeals from
start to finish– Key person for all RAC communications
RAC RESPONSE TEAM:Important Information to Track
• Number of claims requested,
• Number of denied claims,
• Date of reimbursement or recoupment by CMS,
• The amount of reimbursement recouped,
• All communications between the facility and RAC,
• Status of appeals, and
• Complete timelines
How to Prepare:Communication
• Provide Connolly with Your Practice’s Contact Information: http://www.connollyhealthcare.com/RAC/pages/provider_contact_information.aspx
• Document Communications with Medicare • Local Coverage Determinations and Other
General Communications
How to Respond:RESPOND!
• Respond, Respond, Respond– No Response (or an untimely response) equals
automatic denial and potential loss of right to appeal
• Time to Respond: must provide requested records within 45 days
• RAC Team should control this process• Tracking Tools- Record Request Limits
How to Respond:Documentation
• Issue: Majority of RAC audits involve Medical Necessity
• Improve chart documentation
• Submit a COMPLETE copy of the medical record
• Self-assessment of the claim and the medical record before responding
How to Respond:Rebuttal
• Provider can rebut RAC’s initial determination– File with RAC within 15 days after
receipt• When to consider: New documentation to
support the claim• Not required • Does NOT toll deadline for filing formal
appeal
How to Respond:Formal Appeals Process
• 5 Levels (Medicare Appeals Process)– Redetermination– Reconsideration*– Administrative Law Judge Hearing– Medicare Appeals Council Review– Federal Court
Results of the Demonstration
Percentage Appealed
Percentage Favorable to Provider
Percentage of Claims Overturned
Connolly-
Part A9.9% 51.6% 5.1%
Connolly-
Part B7.3% 62.2% 4.6%
All RAC-
Parts A & B22.5% 34.0% 7.6%
• Viant: ???
To Appeal or Not to Appeal?Factors to Consider
• Cost of appeal• Resources• Implications • Quality of documentation• Clinical support• Legal involvement• Time
Formal Appeals Process:Timeline
FI, carrier60 days+14 day extension
QIC60-day time limit
ALI90-day time limit
MAC90-day time limit
US District CourtLast Level- No time limit
Notice Letter
180 Days to File
60 Days to File
60 Days to File
60 Days to File
180-194 Days
240 Days
150Days
150 Days
60+ Days
780-794 Days
120 Days to File
Formal Appeals Process:Appeal Strategies
• Advocate the Merits
• Treating Physician Rule
• Waiver of Liability
• Provider Without Fault
• Reopening Not Based on Good Cause
• Challenging the Statistics
Appeal Strategies:Advocating the Merits
• Not technically a “defense”
• Factual and legal arguments supporting payment– Prepare position paper
• Use qualified expert to confirm medical necessity
Appeal Strategies:Treating Physician Rule
• Medical necessity
• Treating physician is in the best position to judge
• Physician’s determination should be given more weight than RAC– RAC uses medical professionals who
have never met or assessed the patient
Appeal Strategies:Waiver of Liability
• Medical Necessity• Payment permitted if provider “did not
know, and could not reasonably have been expected to know, that payment would not be made for such services”
• Tip: Maintain records of all communications with Medicare representatives– i.e. Overpayment claim overturned in past
Appeal Strategies:Provider Without Fault
• Medical Necessity• Generally, provider considered to be without fault if:
– Exercised reasonable care– Made full disclosure of all material facts– Had a reasonable basis for assuming payment was
correct
• Considers various factors – Age, linguistic limitations, etc.
• Document phone calls, guidance from CMS or carrier
Appeal Strategies:Reopening Not Based on Good Cause
• RACs must adhere to regulatory timeframes for reopening initial determinations
• For Medicare generally:– Within 1 year – for any reason– Within 4 years – for good cause– No deadline if reliable evidence of fraud
• RAC limited 3-year look-back period– Only back to October 2007
• Good Cause?– Limitation: 2009 CMS Transmittal
Appeal Strategies:Challenging the Statistics
• RACs may extrapolate in certain circumstances
• Must follow Medicare’s statistical guidelines
• Actual Overpayment v. Extrapolation– Use a third party expert to challenge the
validity of the extrapolation
Conclusion
• Take steps to prepare NOW– Establish a RAC Team– Limit exposure- Education– Maintain adequate records
• Respond
• Appeals process– Deadlines and Defenses
