RAC Preparation Checklist

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2 RAC Preparation Checklist A. Select an internal RAC Team using individuals from key departments and identify individual roles (if any) in the RAC process. Communicate each individual s roles to others involved in the RAC process. Senior leadership Finance/revenue cycle Clinical documentation management Coding Case management/care coordination Business office (operations, and denials management) Information technology (IT) support services Clinical departments Legal (internal and external) B. Identify and distribute important contact information for RAC audit. Identify the individual in your organization who will serve as the primary RAC point-of-contact ( POC ) and secondary POC. Educate employees about who to contact upon receipt of RAC correspondence. Know the RAC contact information. The contact information for HDI is: Develop and distribute list of external contacts e.g., legal, consultants, accounting. C. Develop tracking and appeals process. Establish a system and identify individuals responsible for tracking medical records requests ( ADRs ) and maintaining copies of the medical documentation submitted to RAC. Instruct individual(s) responsible for tracking and maintaining RAC correspondence to maintain all original correspondence and envelopes. Develop/use RAC Appeal Timeline to keep track of deadlines. Establish system for reviewing adverse results (i.e., who reviews each case, involvement of outside legal counsel or consultant, sequence of review, ultimate decision-maker).

3 RAC Issues Checklist Issues to consider when reviewing a RAC Demand Letter and the RAC s reasons for determining there was an overpayment: Does the RAC allege an overpayment for claims paid over three calendar years prior to the date of the record request (complex medical reviews) or the date of the overpayment notification (automated review)? RACs may not review such claims. Does the RAC allege an overpayment based on claims previously reviewed by another Medicare contractor, such as a Program Safeguard Contractors, Quality Improvement Organizations (QIO) or Comprehensive Error Rate Testing (CERT) program contractor? RACs may not review such claims. Does the RAC base its overpayment determination on an issue that is not a RAC-approved issue? Each RAC issue must be approved before implementation. The chart of RAC-approved issues for Washington State can be found at: Is the authority the RAC cites for its decision (e.g., Medicare Manual provision, coding policy, Local Coverage Determination) applicable to the claim at issue? The right hand column of the chart of RAC-approved issues (website above) cites the relevant authority for each RAC-approved issue. Does the RAC apply the correct version of the authority (e.g., Medicare Manual provision, coding policy, Local Coverage Determination)? Is there other Medicare guidance, newsletters or policies that conflict with the authority the RAC applies to the claim? Does the RAC base its overpayment determination on alleged dating or signature errors? Dating errors and failure to sign documentation does not mean there has been an overpayment. Does the RAC base its overpayment determination on an alleged off-label use of a drug or failure to comply with dosage/ administration requirements? Off-label use of a drug does not mean there has been an overpayment. Does the RAC base its overpayment determination on failure to comply with physician supervision requirements? Consider gathering patient appointment schedules, physician schedules, staff testimony establishing physician s presence in the office on the date at issue.

4 Common RAC Acronyms ALJ: Administrative Law Judge CERT: Comprehensive Error Rate Testing program CMD: Contractor Medical Director (for RAC) CMS: Centers for Medicare and Medicaid Services CPT: Current Procedural Terminology DHHS: Department of Health and Human Services DME: Durable Medical Equipment DOJ: Department of Justice DRG: Diagnosis Related Group ERRP: Error Rate Reduction Plan FFS: Fee for Service HCPCS: Healthcare Common Procedure Coding System HIC: Health Insurance Claim IRF: Inpatient Rehabilitation Facility LCD: Local Coverage Determination MAC: Medicare Administrative Contractor MMA: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 MSP: Medicare Secondary Payer MRN: Medicare Redetermination Notice NCD: National Coverage Determination NPI: National Provider Identifier OIG: Office of Inspector General OMB: Office of Management and Budget PSC: Program Safeguard Contractor QIC: Qualified Independent Contractor QIO: Quality Improvement Organization RAC: Recovery Audit Contractor ROI: Release of Information RVC: RAC Validation Contractor SNF: Skilled Nursing Facility ZPIC: Zone Program Integrity Contractor

5 RAC Process No Automated Review RAC makes a claim determination RAC decides whether Medical records are Required to make determinations CMS New Issue Approval Process New Issues posted to RAC provider website once CMS-approved (may request records for new issue process not posted to web site) Yes Complex Review RAC requests medical records Provider has 45 days plus 10 calendar days mail time to submit. RAC has up to 60 days to review medical records RAC makes a claim determination RAC issues Review Results Letter to provider (does NOT communicate improper amount or appeal rights including no findings ) CMS Provider MAC RAC If no findings STOP

6 RAC Process Automated Review Discussion Period Carrier/FI/MAC Day 1 RAC sends claim info to Carrier/FI/MAC adjusts & issues Remittance Advice (RA) to provider. RAC issues Demand Letter which includes amount and appeal On Day 41, Carrier/FI/MAC recoups by offset. Code N432 rights. Complex Review Discussion Period Provider can pay by check by day 30 or request early recoupment from MAC to avoid interest. Provider can appeal by day 120. Appeal by day 30 will hold recoupment although interest is charged unless outcome is provider favor. CMS Provider MAC RAC