Leah Klusch - RAC Audit [Compatibility Mode]
20 pages
English

Leah Klusch - RAC Audit [Compatibility Mode]

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RAC AuditLeah Klusch, RN, BSN, FACHCALeah KluschExecutive DirectorThe Alliance Training Center330-821-7616leahklusch@sbcglobal.netq Recovery Audit Contractor Programq 3 year, 3 state RAC demonstration program identified 1 billion dollars in improper claims over all healthcare providers reviewedq Demonstration focused on NY, CA, and FL but included providers in other states as wellq Permanent RAC program began in early 2009 to be in all states by January 2010q Goal to identify and recoup $10.8 billion in annual improper Medicare payments (GAO stats)1 " RAC AuditLeah Klusch, RN, BSN, FACHCAqThe RACs will detect and correct past improper payments so that CMS and the Carriers/FIs/MACs can implement actions that will prevent futureimproper payments.–Providers can avoid submitting claims that don t comply with Medicare rules–CMS can lower its error rate and payments–Taxpayers and future Medicare beneficiaries are protectedqMedicare Modernization Act, Section 306:–required 3-year RAC demonstrationqTax Relief and Healthcare Act of 2006, Section 302:–requires a permanent and nationwide RAC program by no later than 2010Both statutes gave CMS the authority to pay RACs on contingency fee basisq RACs review claims on a post payment basisq RACs use the same Medicare policies as FIs, Carriers and MACs –NCDs, LCDs & CMS manualsq Two types of review:–Automated (no medical record needed)–Complex (medical record required)q RACs will NOT be ...

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Nombre de lectures 41
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RAC Audit
Leah Klusch, RN, BSN, FACHCA
Leah Klusch
Executive Director
The Alliance Training Center
330-821-7616
leahklusch@sbcglobal.net
q Recovery Audit Contractor Program
q 3 year, 3 state RAC demonstration program
identified 1 billion dollars in improper claims over all
healthcare providers reviewed
q Demonstration focused on NY, CA, and FL but
included providers in other states as well
q Permanent RAC program began in early 2009 to be
in all states by January 2010
q Goal to identify and recoup $10.8 billion in annual
improper Medicare payments (GAO stats)
1 "

RAC Audit
Leah Klusch, RN, BSN, FACHCA
qThe RACs will detect and correct past improper
payments so that CMS and the Carriers/FIs/MACs
can implement actions that will prevent future
improper payments.
–Providers can avoid submitting claims that don t comply
with Medicare rules
–CMS can lower its error rate and payments
–Taxpayers and future Medicare beneficiaries are protected
qMedicare Modernization Act, Section 306:
–required 3-year RAC demonstration
qTax Relief and Healthcare Act of 2006, Section
302:
–requires a permanent and nationwide RAC program by
no later than 2010
Both statutes gave CMS the authority to pay RACs on
contingency fee basis
q RACs review claims on a post payment basis
q RACs use the same Medicare policies as FIs, Carriers and MACs
–NCDs, LCDs & CMS manuals
q Two types of review:
–Automated (no medical record needed)
–Complex (medical record required)
q RACs will NOT be able to review claims paid prior to October 1,
2007
–RACs will be able to look back three years from the date the
claim was paid
q RACs are required to employ a staff consisting of nurses,
therapists, certified coders, and a physician CMD
2
RAC Audit
Leah Klusch, RN, BSN, FACHCA
qTo detect and correct overpayments and
underpayments
– Refund underpayments to the providers
– Collect overpayments from the providers
q4.5 million claims per work day
q574,000 claims per hour
q9,579 claims per minute
qPayments are made for services that do not meet
Medicare s medical necessity criteria
qProviders fail to submit documentation when
requested, or fail to submit enough documentation
to support the claim
* The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-
Year Demonstration, June 2008
3
RAC Audit
Leah Klusch, RN, BSN, FACHCA
qProviders paid twice because duplicate claims
were submitted
qOther reasons, such as basing claim payments on
outdated fee schedules
qPayments made for services that are incorrectly
coded
* The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-
Year Demonstration, June 2008
qPossible financial exposure
qIncreased scrutiny
qPotential for negative profit margins
qAdministrative and operational burdens to comply
with documentation requests
qExpensive and lengthy appeals process
qCurrent and historical exposure for claims
3 year look back period
qReview data sources
qConvert data to information
qResearch difficult to code/bill areas
qReview each issue
qPerform chart and claim audit
qCommunicate results
4 "
"
RAC Audit
Leah Klusch, RN, BSN, FACHCA
qBetween 2005 and 2009, the RACs indentified:
–900 million in overpayments
–38 million in underpayments
–96% of the claims were overpayments and
only 4% were underpayments
qTo identify improper payments made on claims for
health care services provided to Medicare
Beneficiaries
qThe RAC program is designed to:
Detect and correct past improper payments in the
Medicare FFS program
Provide information to CMS and Medicare contractors to
help prevent fraud in the future and to lower the claims
payment error rate
5 "
"
RAC Audit
Leah Klusch, RN, BSN, FACHCA
qDiversified Collection Services, Inc. of Livermore,
California (Region A) initially working in Maine,
New Hampshire, Vermont, Massachusetts, Rhode
Island, and New York
qCGI Technologies and Solutions, Inc. of Fairfax,
Virginia (Region B) initially working in Michigan,
Indiana, and Minnesota
qConnolly Consulting Associated, Inc. of Wilton,
Connecticut (Region C) initially working in South
Carolina, Florida, Colorado, and New Mexico
q HealthDataInsights, Inc. of Las Vegas, Nevada
(Region D) initially working in Montana, Wyoming,
North Dakota, South Dakota, Utah, and Arizona
q RACs are paid on a contingency basis
If the claim is overturned on appeal, the RAC must repay
its fee
The types of issues undergoing review will be listed on
each RACs website
6






RAC Audit
Leah Klusch, RN, BSN, FACHCA
qEach RAC must hire a full time medical director
qFrom inception through March 27, 2008, it cost the
RACs only .20 to collect a dollar
qDuring the demonstration program RACs collected
$187.2 million in contingency fees
qRACs review a huge number of claims using
automation provider has the burden to respond
or appeal
qRACs receive payment for each improper
payment corrected they are on the hunt for
mistakes
qContingency Fees Region A 12.45%, Region B
12.50 %, Region C 9%, Region D 9.49%
qImproper payments were estimated at 10.8 billion
dollars in 2007
7 "

"
"
"
RAC Audit
Leah Klusch, RN, BSN, FACHCA
qThe main reasons for the improper payments
were:
Payments were made for services that don t meet
Medicare medical necessity requirements
Payments were made for services that are incorrectly
coded
qThe main reasons for the improper payments
were:
Providers failed to submit documentation when
requested, or
Failed to submit enough documentation to support the
claim
qWHAT DOCUMENT DOES YOUR
FACILITY USE AS ITS
AUTHORITATIVE SOURCE FOR
MEDICARE BENEFIT
DETERMINATIONS AND
COVERAGE DECISIONS BY YOUR
INTERDISCIPLINARY TEAM ?
8



RAC Audit
Leah Klusch, RN, BSN, FACHCA
qHOW AND WHERE DO YOU
DOCUMENT YOUR DECISIONS ON
MEDICARE COVERAGE BOTH AT
ADMISSION AND DURING THE
COVERED STAY IN THE SKILLED
NURSING ENVIRONMENT?
q These two review processes automated
review and complex review are similar to those
employed by the Medicare claims processing
contractors to identify improper payments as
stated in the pilot program report.
q RACs identify improper payments via automation where
the provider clearly billed in violation of Medicare Policy
q This is an off site electronic review of claims without
human analysis
q Facility is not notified until an error is found and payment
is either adjusted or denied
q Uses the data base from the MDS and the UB-04 files
and looks for missing items or coding errors
q Payment due within 40 days or recoupment becomes
automatic (with interest accrued from the date of the
demand letter)
9

RAC Audit
Leah Klusch, RN, BSN, FACHCA
qMismatched ARD dates on the MDS and the
Universal Billing Form UB-04
qDuplicate claims
qCoding errors HIPPS and modifiers RUG scores
and reasons for assessment
qBills submitted prior to MDS submitted and
validated in the state data base
qRACs use proprietary techniques to indentify
claims that clearly contained errors resulting in
improper payments and those that likely contained
errors resulting in improper payments
qIn the case of a clear improper payment, the
provider is contacted and an overpayment is
requested or the underpayment paid
qThe contractors will identify likely improper
payments and request medical records from the
provider to conduct more in depth reviews
qReviews can be discussed with the internal staff at
the facility request important step
qProviders will have 45-55 days to provide
requested records and RAC will have to make
determinations on coverage within 60 days
10

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