Medicare Recovery Audit Medicare Recovery Audit Contractor (RAC) ProgramContractor (RAC) Program

Jennifer Amann, MBAJennifer Amann, MBA

Healthcare Resource Providers, LLCHealthcare Resource Providers, LLC

Recovery Audit ContractorsRecovery Audit Contractors

Goal: Identify overpayments and Goal: Identify overpayments and underpayments made by CMS to underpayments made by CMS to providersprovidersFour contractors hired by Medicare to Four contractors hired by Medicare to conduct auditsconduct audits– Regional rollout started in March 2009 Regional rollout started in March 2009 – Scheduled to involve all 50 states by 2010Scheduled to involve all 50 states by 2010

Paid based on “savings” to Medicare Paid based on “savings” to Medicare programprogram– Incentive to find incorrect overpaymentsIncentive to find incorrect overpayments

RAC ContractorsRAC Contractors

Diversified Collection Services, Inc. (A)Diversified Collection Services, Inc. (A)– www.dcsrac.com www.dcsrac.com

CGI Technologies and Solutions, Inc. (B)CGI Technologies and Solutions, Inc. (B)– www.racb.cgi.com www.racb.cgi.com

Connolly Consulting Associates, Inc. (C)Connolly Consulting Associates, Inc. (C)– www.connollyhealthcare.com www.connollyhealthcare.com

HealthDataInsights (D)HealthDataInsights (D)– www.racinfo.healthdatainsights.com www.racinfo.healthdatainsights.com

RAC WebsitesRAC Websites

Sample audit request lettersSample audit request letters

List of approved issues for reviewList of approved issues for review– Example: Diversified Collection ServicesExample: Diversified Collection Services

7 Inpatient hospital issues (most DRG related)7 Inpatient hospital issues (most DRG related)

11 DME11 DME

1 Ambulance providers1 Ambulance providers

1 Clinical social workers (CSW)1 Clinical social workers (CSW)

– Detailed descriptions and policy-related links providedDetailed descriptions and policy-related links provided

Radiology procedures currently most likely to be Radiology procedures currently most likely to be pulled in from inpatient hospital issuespulled in from inpatient hospital issues

Medical Record ReviewMedical Record Review

RACs must have a physician medical RACs must have a physician medical director and certified codersdirector and certified coders– Must provide credentials upon requestMust provide credentials upon request

No audits on claims paid before 10/1/2007No audits on claims paid before 10/1/2007– Limited to 3-year retrospective reviewLimited to 3-year retrospective review

CMS sets limits per yearCMS sets limits per year– Covers the number of medical records that Covers the number of medical records that

can be requested per 45-day periodcan be requested per 45-day period

Medical Record Review LimitationsMedical Record Review Limitations

2009 limits for Part B providers2009 limits for Part B providers– 10 records for solo practitioners10 records for solo practitioners– 20 for 2-5 physicians20 for 2-5 physicians– 30 for 6 -15 physicians30 for 6 -15 physicians– 50 for groups of 16 or more50 for groups of 16 or more

Number of records can be adjusted Number of records can be adjusted annuallyannually– No updates for 2010 published yetNo updates for 2010 published yet

RAC LettersRAC Letters

Specify coverage, coding or payment policy Specify coverage, coding or payment policy violatedviolatedReason for reviewReason for reviewDescription of overpayment situationDescription of overpayment situationRecommended corrective actionsRecommended corrective actionsExplanation of: Explanation of: – Provider’s right to submit a rebuttal statement prior to Provider’s right to submit a rebuttal statement prior to

recoupment of overpaymentsrecoupment of overpayments– Procedures for recovery of overpaymentsProcedures for recovery of overpayments– Right to request extended repayment scheduleRight to request extended repayment schedule– Right to appealRight to appeal– Other requirements for written notificationsOther requirements for written notifications

Audit ProcessAudit Process

Typically practices will receive letters Typically practices will receive letters requesting medical recordsrequesting medical records

Auditors have authority to go on site to Auditors have authority to go on site to view and copy recordsview and copy records– Practices can refuse access, howeverPractices can refuse access, however– RAC then needs to provide written request for RAC then needs to provide written request for

copiescopies

Educational ResourcesEducational Resources

Watch for RAC contractor outreach activitiesWatch for RAC contractor outreach activities– Several have scheduled presentations at industry Several have scheduled presentations at industry

association meetingsassociation meetings

CMS has announced series of free educational CMS has announced series of free educational teleconferencesteleconferences– April 28, 2010April 28, 2010

RAC 101RAC 101

– May 12, 2010May 12, 2010RAC 101 for Physicians RAC 101 for Physicians

– Calls scheduled 1:00 – 2:30 ESTCalls scheduled 1:00 – 2:30 EST877-251-0301877-251-0301

Preparing for the RACPreparing for the RAC

What were the results of recent CERT What were the results of recent CERT audits?audits?

Track coding and medical necessity Track coding and medical necessity denials for patternsdenials for patterns

Conduct internal coding auditsConduct internal coding audits– What was ordered was what was doneWhat was ordered was what was done– What was done was what was billedWhat was done was what was billed– What was billed was what was paidWhat was billed was what was paid

The Bigger PictureThe Bigger Picture

Overall Medicare auditing/enforcement actionsOverall Medicare auditing/enforcement actions– CERTCERT– ZPIC (Medicare Zone Program Integrity Contractors)ZPIC (Medicare Zone Program Integrity Contractors)– RACRAC

ZPIC compliance efforts (assigned based on MAC ZPIC compliance efforts (assigned based on MAC jurisdictions)jurisdictions)– Data analysis and data miningData analysis and data mining– Medicare reviews to support “benefit integrity”Medicare reviews to support “benefit integrity”– Supporting law enforcement and answering complaintsSupporting law enforcement and answering complaints– Investigating fraud and abuseInvestigating fraud and abuse– Recommending recovery of Federal funds through Recommending recovery of Federal funds through

administrative actionadministrative action– Referring cases to law enforcementReferring cases to law enforcement

Thank you!Thank you!

Jennifer Amann, MBA

Healthcare Resource Providers, LLC

P.O. Box 90190

Albuquerque, NM 87199

Cell: 817-406-3355

jkroken@radconsultants.com

www.radconsultants.com