Transcript ATTACK of the RAC

ATTACK
of the
RAC
How to prepare and
respond to RAC audits
Overview
• Current Status
• How to Prepare
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–
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
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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/pr
ovider_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
ConnollyPart A
9.9%
51.6%
5.1%
ConnollyPart B
7.3%
62.2%
4.6%
All RACParts A & B
22.5%
34.0%
7.6%
• Viant: ???
To Appeal or Not to Appeal?
Factors to Consider
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Cost of appeal
Resources
Implications
Quality of documentation
Clinical support
Legal involvement
Time
Formal Appeals Process:
Timeline
180-194
Days
Notice Letter
120 Days
to File
FI, carrier
60 days+14 day extension
180 Days to File
240
Days
780794
Days
QIC
60-day time limit
60 Days to File
150
Days
ALI
90-day time limit
60 Days to File
150
Days
MAC
90-day time limit
60 Days to File
60+
Days
US District Court
Last Level- No time limit
Formal Appeals Process:
Appeal Strategies
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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
Questions
• Patrick C. Devine, Jr.
[email protected]
757.629.0614
• Courtney A. Miller
[email protected]
757.629.0665