Recovery Audit Contractors (RAC\'s) Medicare Medicaid and Commercial Ins investigations What You Need to Know
Transcript of Rac Auditslidesforseminars
1. Recovery Audit Contractors (RACs) Medicare. Medicaid and
Commercial Insurance Investigations What you Need to Know
2. Agenda
What is the Recovery Audit Contract?
How does the RACs affect providers?
Goals of the government Contractors?
How do Providers Prepare?
What Commercial Insurance Companies are doing
Call in the Marines!
3. Recovery Audit Contract-RAC
Government awarded March 5, 2009:
4 (Four) Private firms to perform medical records and billing
audits on providers in all 50 states and Puerto Rico
Inpatient
Outpatient (clinics and Ambulatory Surgery)
Home Health
Nursing Home
4. Regions and timelines *RACs are required to perform outreach
programs for all providers in their region From CMS D C B A March
1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009
March 1, 2009 August 1, 2009 August 1, 2009 August 1, 2009 Provider
Outreach Claims Available for Analysis Earliest Correspondence
5. How the RAC affect the Provider If the providers bill
Fee-for-Service Medicare, Medicaid or Commercial Insurance
programs, their claims will be subject to review by the
investigators and auditors
6. Who has the Authority
Medicare (CMS) was authorized by Congress to perform audits on
all physicians, hospitals and allied health providers with the
purpose of identifying:
Documentation and coding inconsistencies
Overpayments (& Underpayments) made to the providers based
on the findings
Clear documentation to support the medical necessity of the
services being provided or dispensed
$1 billion identified overpayments in 3 states in ONE year
(California, New York and Florida Hospitals only )
7. What about the other entities
Medicaid ( partially funded by the federal government and
managed by each state )
They are hiring firms like Healthnet Federal Services to mimic
the identical issues as the federal government
United, Aetna and All others-
because they have implied authority to review all providers
claims
codeXpress. Providers Coding Resource
8. What does the RAC do?
Review claims and medical records on a post payment basis
Review claims paid prior to October 1, 2007
RACs will be able to review medical records three years from
the date the claim were paid
Collect overpaid claims paid
9. Fiscal Year 09 Medical Record Limits
Physicians
Single Practitioner : 10 medical records per 45 days per
NPI
Partnerships 2-5 individuals: 20 medical records per 45 days
per NPI
Groups 6-15 individuals: 30 medical records per 45 days per
NPI
Large Group Practices 16+ individuals: 50 medical records per
45 days per NPI
Other Part B Billers (DME, Labs)
1% of the average monthly Medicare claims (max 200) per NPI per
45 days
10. How to Prepare Your Providers
Identify improper coding and billing that is based on
documentation in the patients medical record
Assist the providers with training programs that can ensure
they are meeting documentation compliance
Be available to assist the office in the event that the RAC
communicates an audit
11. How Providers Get Prepared
Perform an independent assessment to identify areas of
non-compliance with Medicare/Medicaid rules
Identify any corrective actions required for compliance
Implement any required changes to stay in compliance
12. Importance of Documentation Compliance
The medical record or chart notes must match the codes you
submit
Evaluation & Management (office visit)
Diagnosis
Injections
Supplies
Medical Necessity must clearly state the need for all services
provided or prescribed.
13. Beyond the BaseLine Review
Billing team must track all denied claims
Identify all the issues
Look for patterns
Deploy any corrective actions to avoid improper payments
Be the solution
14. When the RAC arrives
Must provide a clear respond to the letter within 45 days
Retain a certified coder review the records prior to
submission
Send copies of the charts to the RAC- signature required
notification of receipt.
Digitized/electronic file of your charts and supporting
documentation.
WATCH THE MAIL FOR A RESPONSE
15. Next Steps from the RAC
RAC will issue a Demand letter
RAC will offer an opportunity for the provider to appeal the
decision
16. The Collection Process
Demand letter comes from the (RAC)
Issue Remittance Advice
Remark Code N432: Adjustment Based on Recovery Audit
Recoups by offset unless provider has submitted a check or a
valid appeal
Providers HAVE NO CHOICE
THEY TAKE THE $$ DIRECTLY FROM YOUR MEDICARE CHECK
17. Disagreement No Appeal
Send check on or before Day 30 -if do not appeal
Recoupment by Medicare (overpayment + interest) on Day 41 and
do not appeal
Extended Payment Plan-Request or apply for extended payment
plan (overpayment + interest) and do not appeal
18. Appeals
Pay by check on or before Day 30 (interest is not assessed) and
file an appeal by Day 120
Allow recoupment (overpayment + interest) on Day 41 and file an
appeal by Day 120
Stop the recoupment by filing an appeal before Day 31
Request or apply for extended payment plan (overpayment +
interest) and appeal by Day 120
19. What to Expect Next
Repeat the exact same process every 45 days until they find no
more overpayments
20. Where do they turn- YOU
YOU become their team of RAC Service Advisors
Get the Base Line Audit as soon as possible
Determine where the Practice will stand with the RAC team
Become the go to team for the Practice when the RAC
arrives
21. RAC Preparation Support Medicare Documentation & Coding
Benchmark Audit
Random selection of 50 office notes
Release of Information
Fax to HIPAA secure site (iDocumentNow) for certified coders to
review Documentation and coding Compliance audit performed by
certified coders Web-based Training Audit Report
Eliminates copying
No space for auditor required
RAC Audit Management
RAC Findings Review
RAC Appeal
All Medical Specialties
Designed for Physician
Training for your coding team
Sample report to follow
22. Guess whos coming to the Audit Table
Medicaid
United Health, Aetna
And other commercial payers
What they are saying..
if the providers are miscoding for Medicare they are miscoding
our claims also
23. Review
The RAC is serious- Providers need to know and understand the
implications
Determine where the practice will stand
Understand that you may need to call for help to manage the
process
Medicare is likely NOT the only payer going to take a
peek.