Transcript Slide 1

Natalie Warf, CHP, CPC
Privacy Administrator
HCA Regulatory Compliance Support
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166 hospitals,168 outpatient centers and
400+ physician practices in 20 states and
England
More than 40 facilities had some RAC activity
◦ Predominately in Florida
 HDI – HealthData Insights
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Facilities located in all 4 permanent program
RAC regions
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Organization is the Key
The “Rules” Change
Track, Trend & Report
Know the Process & Associated Timelines
Understand the RAC Recoupment Process
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Senior Leader
◦ CFO, CEO
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Responsibilities
◦ Provide strategic priority and direction for RAC
program
◦ Understand the overall RAC impact to facility
 Financial
 Staffing and productivity
 ROI contracts
◦ Ensure the facility is ready and responding out of
the gate
◦ Designate the facility RAC liaison
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RAC “Liaison” or “Coordinator”
◦ Designated by senior leadership
◦ Over all types of government audits? RACs, MICs…
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Responsibilities
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Ownership and coordination of facility RAC activity
Tracks timeliness
Oversees the logging/tracking mechanism
Leads the RAC team
The RAC “go to” person
Potential candidates
◦ HIM Director
◦ Case Manager
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Ensure all affected areas in the loop
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Case Management
HIM
Physician Advisor
Billing Office
Mailroom
RAC Liaison
Senior Leadership
Medical director
Staff physician
Outpatient entities
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Internal communication plan
◦ General RAC awareness
◦ Areas of responsibility
◦ Escalation process
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External communication plan
◦ Know your contacts and develop relationships,
when applicable
 The RAC, CMS Project Officers, FI/MAC, QIC
 Region C CMS PO: [email protected]
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Liaison between CMS and the RAC
Grant extensions to the RAC
Approve RAC sample letters
Receives copies of provider dissatisfaction
letters/correspondence
Suppresses or excludes claims
Approves all web-based applications
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Can work well for a chain or health system
May reduce cost and increase accountability
Potential functions for centralization–
whatever works for your system
◦ All correspondence logged and processed
◦ Appeals prepared, sent and tracked
 Centralize by type: coding vs. medical necessity
◦ Account follow-up performed
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Single facility may centralize to a person or
department
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Topic
Medical Director
Coding Experts
Credentials provided
External validation process
RAC must re-pay contingency if
provider wins appeal
Standardized provider letters
Maximum look-back period
Demonstration RACs
Not Required
Optional
Not Required
Not required
Only at first level
Not Required
3 years past date of initial
payment
Optional
Limits on medical record
requests
Reason for review on provider
Not Required
letters
Time frame for RACs to pay for Not set
medical records
Permanent RACs
Required
Required
Required
Required
Required at all
levels
Required
3 Years (not prior to
10/1/07)
Required
Required
Within 45 days of
receipt
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What is it?
◦ RAC Contract
Requirements
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Where is it found?
◦ CMS Website or
FedBizOpps
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What’s in it for you?
◦ Guides you on
whether the RAC is
following the “rules”
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Examples
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Coding experts
External validation
Provider outreach
Look back period
Medical record limits
Standardized letters
Contingency fees
Contractor websites
Electronic
records/submission
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*Expected to change in 2010 – TAX ID based instead of NPI driven
Provider Type
Medical Record Limit
Part A
Inpatient Hospital, IRF, SNF, Hospice
10% average monthly Medicare claims
(max 200) per 45 days, per NPI
Other Part A
(Outpatient Hospital, Home Health)
1% average monthly Medicare services
(max 200) per 45 days, per NPI
Part B
Solo Practitioner
10 medical records per 45 days
Partnership of 2-5 individuals
20 medical records per 45 days
Group of 6-15 individuals
30 medical records per 45 days
Large Group (16+ individuals)
50 medical records per 45 days
Other Part B Billers
(DME, Lab)
1% average monthly Medicare services
per 45 days
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CMS Main RAC Website:
◦ www.cms.hhs.gov/RAC
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FedBizOpps Website:
◦ www.fbo.gov
◦ Use this site to view contract information
◦ Federal website providing government contracting
opportunities
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Participate in advocacy groups
Work with the THA/THIMA
Provide data to the AHA by using RACTrac
◦ www.aha.org/aha/issues/RAC/ractrac.html
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Attend provider outreach sessions
Contact the RAC or CMS project officer when
you have problems
Complete provider satisfaction surveys
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Monitor RAC websites for new issues
◦ Automated reviews
 Verify appropriate billing edits in place and working
 Work with your billing vendor to create/enhance edits
 Examples: Blood Transfusions, IV Hydration
◦ Complex reviews
 Ensure proper procedures in place
 Case management for one day stay
 Documentation guidelines followed
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Know your weak spots
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Use a tracking tool
◦ External vendors
◦ In-house created database
◦ Centralized spreadsheet
 Consider one person for data entry
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Suggested data to track (account level detail)
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Dates correspondence received and sent
Standardized denial reasons
Appeal activity (dates, outcomes)
Financials
More data tracked = better reporting
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Review data for trends
◦ DRG
 Most reviewed?
 Change rate?
◦ Discharge Status
 Common issues?
◦ Medical Necessity
 Documentation issues? Specific provider?
 Process improvements needed?
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Appeals data
◦ Consistently overturning RAC denials on appeal?
◦ Calculate success rates
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Senior Management
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RAC Team
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Top reviewed DRGs, medical necessity, denial rates
Appeals/Billing Staff
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Deadline statistics, hot review items, frequencies of reviews,
appeal statistics
Medical Staff
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Summarize high level, appeal status, takebacks, dollars at risk
Accounts for follow-up (e.g., medical records, appeals)
Advocacy Reporting (e.g., AHA RACTrac)
Use to educate and improve processes/outcomes
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CMS approves RAC issue
The RAC uses data mining and internal
processes to identify improper payments
The RAC issues a demand letter
The FI/MAC/Carrier issues a remittance
advice
The provider may
◦ Agree
◦ Discuss the issue with the RAC
◦ Submit a rebuttal or appeal
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CMS approves RAC issue
The RAC issues a medical record request
Provider submits records
The RAC reviews and sends
◦ Review Results Letter
◦ Demand Letter
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The FI/MAC/Carrier issues an RA
The provider may
◦ Agree
◦ Discuss the issue with the RAC
◦ Submit a rebuttal or appeal
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• Medical records due in 45 days
• The RAC must respond to records in 60 days
Levels
Level One
Level Two
Level Three
Level Four
Civil
Action
Contractor
FI/MAC/Carrier
Qualified
Independent
Contractor (QIC)
Administrative
Law Judge (ALJ)
Departmental
Appeals
Board (DAB)
U.S.
District
Court
Provider Must
Appeal Within:
120 days from
RAC
determination
180 days from
FI/MAC
determination
60 days from
QIC
determination
60 days from
ALJ decision
60 days
from DAB
decision
Contractor
Response:
60 days
60 days
90 days
90 days
Redetermination
Reconsideration
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Review RAC decision
Don’t assume the RAC is “right”
Do them timely
Don’t forget the basics to avoid
dismissals
◦ Dismissal = required elements missing
from appeal
◦ Beneficiary Name, HIC #, Dates of
Service, Item/Service appealed, and
name and signature of appellant
Justify – cite Interqual® or Milliman®
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Definitions
o Recoupment and offset = Medicare takes the money due for
an overpayment by deducting it from another RA
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Remark code = Informational designation on a Medicare RA
that provides clarification on the status of the claim
Remark Code N432 = Adjustment based on a Recovery
Audit
 Tells the provider the claim was adjusted due to a RAC
review
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RAC demand letter and RA with remark code N432 by FI/MAC
are issued
 This starts the appeals and recoupment clock!
 Use this to reconcile RAC activity
Recoupment will begin day 41 if a valid first level appeal is
not received by day 30 at FI/MAC
Provider pays interest if auto-recouped on day 41
Recoupments are held if valid appeal received by day 30 for
level 1 appeal or day 60 for level 2 appeal
Level 3 and higher appeals do not stop the takeback
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Review the Limitation on Recoupment final
rule
Determine if the facility can meet a 30 day 1st
level appeal turnaround
Billing office should be on the look-out
Reconcile data
Interest
◦ Continues to accrue even if held and must be repaid
if appeal not favorable
◦ Refunded to provider if denial overturned
◦ Rate set quarterly by Treasury Dept
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Thank you!
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