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Additional RAC Information

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  • February 4, 2010: The Centers for Medicaid and Medicare Services (CMS) announced expansion of RAC medical request limits to all institutional providers. The additional documentation request (ADR) limits will be set by each RAC on an annual basis to establish a per campus maximum amount of medical records that may be requested within a 45-day period. The RAC for Region D, HealthDataInsights (HDI) has already prepared ADR letters for institutional providers in its Region. To read more, visit our blog: www.wachlerblog.com.
  • January 22, 2010: CGI posted several new RAC issues for all states in Region B. There are new issues for the following types of claims: outpatient hospital and physician claims, inpatient hospital claims, CSW providers, and non-medical necessity DRG-validation inpatient claims.
  • January 21, 2010: DCS Healthcare, the RAC for Region A, added various new CMS-approved RAC issues for all Region A states. The new issues include: ambulance unbundled services during an inpatient hospital stay, and three new RAC issues for non-medical necessity DRG-validation inpatient claims review.
  • January 20, 2010: The RAC for Region D, HDI, added new RAC issues for all states in Region D. The issues include new non-medical necessity DRG validation issues, Part B, and DME claim issues.
  • January 11, 2010: In December CMS released 16 new, updated RAC FAQs on its website. Some of the new FAQs involve: provider self-audits, the RAC appeal process, RAC payment for finding underpayments, and eligible claims under the RAC program. Click here to read more about these FAQs.
  • January 8, 2010: The RAC for Region A, DCS Healthcare, added six CMS-approved RAC issues for DME claim review. These new issues apply to all Region A states. Click here for more information on these DME issues.
  • January 7, 2010: Connolly Healthcare, the RAC for Region C added many new RAC issues for all states in Region C. Many of the new issues released relate to DME claims. Visit Connolly Healthcare's website for more detail on these issues.
  • December 28, 2009: DCS Healthcare has added new RAC issues to various states. The first new issue involves Clinical Social Worker (CSW) services and applies to Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont. DCS also added six new issues for DME claim review in all states in Region A. These issues include: wheel attachment with new non-wheeled walker; headrest with power operated vehicle or a power wheelchair with a captain's chair seat; multiple DME rentals within one month; prosthetic additions with initial or preparatory knee prosthesis; lower limb suction valve prosthesis; solid insert with seat or back wheelchair cushions.
  • December 28, 2009: HealthDataInsights (HDI) has added three new RAC issues for all states in Region D. The new issues are: Skilled Nursing Facility (SNF) Consolidated Billing; A4221 Excessive Units; Prosthetic Bundling.
  • December 24, 2009: Providers have begun to receive medical records documentation requests following the approval of the first set of issues for complex RAC review. Connolly Healthcare approved to audit various DRG validation issues in these Region C states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas. Of the hospitals that have received documentation requests, one noted that its extensive preparation for the RAC program has paid off allowing the hospital to work efficiently to fulfill the documentation requests.
  • December 11, 2009: The Senate health reform bill expands the RAC program to Medicaid, Medicare Parts C and D. The expansion into these areas is proposed to be in place by December 31, 2010. The Medicaid RACs would also be paid on a contingency-fee basis, and states would have the ability to contract with RACs to find payment errors. In addition, the bill would require states to have an appeals process for entities that disagree with determinations of the contractors.
  • December 10, 2009: The RAC for Region D, HealthDataInsights (HDI), posted new RAC issues approved by CMS for Part B claims. The new issue is labeled as facility vs. nonfacility reimbursement (inpatient.)
  • December 9, 2009: The RAC for Region B, CGI, added a new audit issue for DME claims: wheelchair bundling. It also expanded the already identified issues to new states. States in Region B included: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin.
  • December 4, 2009: The RAC for Region C, Connolly Healthcare, published the first set of CMS approved audit issues for complex reviews. The complex reviews will be for Coding/DRG validation and for discharge status code assignment for several MS-DRGs. These complex reviews do not yet include medical necessity determinations. The DRG-validation issues are approved for: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas. Please visit Connolly Healthcare's website to see a list of the MS-DRGs.
  • December 2, 2009: CMS announced FY 2010 RAC DRG Validation ADR limits.
  • November 12, 2009: The RAC for Region D, HealthDataInsights (HDI) added new issues for approved RAC audits for DME claims. The new issues include: (1) PEN supplies more than one time a day and (2) infusion pump denied/accessories and drug codes should be denied.
  • November 12, 2009: The Center for Medicare and Medicaid Services (CMS) released three transmittals within three weeks (R5610TN, R5710TN, R5730TN) highlighting technical changes made to “enhance” the RAC mass adjustment process. The changes will automate the process of initiating mass adjustments of similar claims and/or service types. RACs will be able to upload files to the intermediary to make mass adjustments. Thus, automated denials will be much quicker for RACs and lead to the potential for even more denials for providers. With these technical changes on the horizon, it is important to remember that the RAC denial limitation of 200 every 45 days only applies to complex audits; there are no such limits for the automatic reviews that RACs can perform.
  • November 2009: Diversified Collection Services, the RAC for Region A has the opportunity on their website for providers to enroll a contact person for their facilities. It is recommended that facilities enroll a contact person as soon as possible.
  • November 5, 2009: Requested medical records may be submitted by CD or DVD, but the format must be TIFF or PDF. In addition, the submission must be in a tamper-proof package and the image file number must be made the same as the requested claim number.
  • October 29, 2009: The RAC for Region B, CGI, posted three new issues for review in Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin. The new approved issues for physician and outpatient hospital claim review included: Neulasta, Once in a Lifetime Procedures, and Untimed Codes. This addition means that there are approved issues for RAC auditing in all states.
  • October 29, 2009: CMS approved a new issue, knee orthotic bundling, for DME provider audits in Region D.
  • October 2009: On October 15, 2009 CMS release an FAQ on the appearance of code N432 on remittance advice. The FAQ addressed the concern that code N432 was being superseded in some systems by code N469, the Section 935 Limitation on Recoupment Code. CMS indicated that it is working to correct the problem.
  • October 2009: According to an American Hospital Association (AHA) RAC program update, all four RACS are conducting automated audits, but only 16 of the 23 audits underway are on hospital outpatient claims. AHA also indicated that RACs have requested the ability to audit more than 100 issues, but these issues have yet to be approved by CMS.
  • October 2009: The RAC for Region D, HealthDataInsights (HDI) announced two new issues to audit DME providers in region D states: Urological bundling and Wheelchair bundling.
  • October 2009: CMS planned a town hall meeting for November 5 from 1-3:30 p.m. EST to discuss appeals of Medicare payment denials. CMS will release more information in the upcoming weeks.
  • October 2009: Beginning in 2010, the Office of Inspector General (OIG) plans to review the progress of many Medicare and Medicaid auditing programs, and CMS' oversight of the programs.
  • October 2009: DCS Healthcare, the RAC for Region A, was the last RAC to announce the first CMS-approved issues for audits in Region A. The three issues are applicable to DME suppliers in Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. The issues include: pharmacy supply and dispensing fees, wheelchair bundling, and urological bundling.
  • October 2009: CMS released a new RAC FAQ involving the RAC discussion period. The FAQ states that the discussion period begins with the time of notification through the time recoupment occurs. The discussion period normally requires written notification to the RAC and does not extend the providers time frames.
  • September 2009: On September 16, the Centers for Medicare and Medicaid Services issued a Final Rule Limiting Recoupment of Provider and Supplier overpayments. Click here to learn more!
  • September 2009: On September 10th the RAC for Region C, Connolly Healthcare, approved several issues subject to audit for North Carolina providers. Some of the issues are: untimed codes, once in a lifetime procedures, pediatric codes exceeding age parameters.
  • September 2009: CMS released transmittal 302 which explains the authority RACs, MACs, and other Medicare auditors have to apply exceptions to certain LCD clinically reasonable and necessary requirements. The exceptions, CMS indicated, should be rare and applied only under unusual circumstances.
  • August 2009: The RAC for Region B, CGI Federal, posted the first set of issues eligible for RAC audits in Indiana, Michigan and Minnesota. These states are the three “yellow” Region B states where RAC audits are scheduled to begin first.
  • August 2009: Connolly Healthcare, the RAC for Region C approved issues eligible for RAC audits in Alabama and Georgia. In addition, Connolly has been approved to audit Durable Medicare Equipment (DME) providers on two issues: Wheelchair bundling and Urological Bundling.
  • August 2009: Andrew Wachler was featured in an article in the August 2009 OR Manager regarding Ambulatory Surgery Centers recouping costs on out-of-network. Click here for more information.
  • August 2009: Connolly Healthcare, the RAC for Region C, may begin auditing Florida providers on specified issues. The approved issues for Florida are similar to those for South Carolina, another state located in Region C, but with some differences. Click here to view the approved issues for Florida and South Carolina.
  • August 2009: The RAC for Region D, HealthDataInsights (HDI), has launched its new RAC website and posted issues eligible for RAC review throughout the region.
  • August 14, 2009: On August 13, Mr. Wachler co-presented a Teleconference for the American Bar Association with Connie Leonard, Director of the Division of Recovery Audit Operations for the Centers for Medicare & Medicaid Services. Click here to read more!
  • August 2009: Andrew Wachler was featured in an article on Medicare appeals from HCPro's August Issue. Click here for more information.
  • July 29, 2009: Wachler & Associates featured in Detroit Legal News for work on RAC audits
  • June 24, 2009: CMS releases a RAC Review Phase-In Strategy & RAC Phase-In Map
  • June 12, 2009: CMS updates to the Medicare Financial Management Manual RAC information