Recovery Audit Contractors version 3

Karenl

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• Publié par: Saem
• Nombre de lectures: 45
• Langue: English

Extrait

Recovery Audit Contractors (RACs ) Support a Temporary Freeze on RACs Reps.Lois Capps(D-CA) andDevin Nunes(R-CA) introduced the“Medicare Recovery Audit Contractor Program Moratorium Act of 2007”(HR 4105) that would enact a one-year, nationwide moratorium on the Recovery Audit Contract (RAC) program.The legislation would require the Centers for Medicare & Medicaid Services (CMS) and the Government Accountability Office (GAO) to evaluate the RAC program and report to Congress on their findings. The CMS report would include specific information about the number and types of claims reviewed, the types of reviews, and the outcome of appeals. The GAO report would examine the RAC program’s compliance with current Medicare policy as well as compare its efficiency with existing Medicare quality improvement programs and contractors. CMS would also be required to submit quarterly reports to Congress once the RAC program resumes There are several major areas of concern with regard to the RAC program: •RACs are paid a fee based on a percentage of overpayments they collect which has created a system which favors aggressive denials. Instead, the RACs should be paid a contractual amount unrelated to collections. •RACs should not review claims based on medical necessity because practice patterns vary by community. •Additionally, RACs communicate with the hospitals via regular mail service and there is no way of tracking the process.CMS should establish an electronic platform which would allow providers to track the status of claims being reviewed and appeals activities. •CMS should develop a quarterly “report card” on the RAC activity including such information as number and types of claims reviewed and the types of reviews conducted. •CMS shouldFurthermore, the RACs have not been looking at underpayments to a reasonable degree. provide oversight to assure RACs examine improper underpayment as well. •The look-back period for reviews should be limited to twelve months but not include the current fiscal year. Thecurrent fiscal year should continue to be under the purview of the existing contractors. •There are no penalties on the RACs for improper and abusive behavior and CMS has not provided sufficient oversight of the RACs activities. •CMS should conduct provider education opportunities to correct problematic practices identified by the RACs. The RAC demonstration was created by “Medicare Prescription Drug Improvement and Modernization Act of 2003” (PL 108-173, Section 306) to identify improper Medicare overpayments and underpayments.RACs are paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers.Florida, California and New York were selected as the demonstration sites. Under the demonstration program, RACs could review the three years of provider claims for hospital inpatient and outpatient, skilled nursing facility, physician, ambulance and laboratory, as well as durable medical equipment. The RACs use proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity and coding. Corporate OfficeRegional OfficeWashington, D.C. Office  306 East College Avenue307 Park Lake Circle444 N. Capitol Street, NW, #532  Tallahassee, FL 323011522Washington, D.C. 20001 Orlando,FL 32803  (850) 2229800Fax: (850) 5616230(407) 8416230Fax: (407) 4225948(202) 4344848Fax: (202) 4344846 www.flhealthjobs.comwww.fha.org www.flacareers.com

The “Tax Relief and Health Care Actof 2006” (PL 109-432, Section 302) made the program permanent and extended it to all states by no later that 2010. The Centers for Medicare & Medicaid Services has already expanded RAC review to Arizona, Massachusetts and South Carolina and intends to extend the program with different states coming under review in March 2008, October 2008 and January 2009. During fiscal year 2007, the RACs collected $357 million in overpayments and found $14.3 million in underpayments. An additional amount was identified for collections, but the final outcome has yet to be determined due to appeals. Nearly $14.1 million was spent in program operation and contingency fees paid to the RACs during fiscal year 2006.In FY06, only 3 percent of the improper payments found by RACs were for underpayments. Each of the demonstration sites has experienced problems to varying degrees.InFlorida, the RAC, Health Data Insights, began looking at coding errors and other typical compliance concerns. As part of the coding reviews, they mistakenly identified a number of claims as being miscoded but had been employing coding guidance that was not in place when the claims were originally submitted.Future reviews focused on discharge status and HDI denied a large number of claims through the automated review process as having inappropriate discharge destinations coded.However, there had been a clarification in policy which the RAC was applying to the reviewed claims, although the clarification was issued after the date the claims were originally billed.The key area of focus for HDI today is short stay admissions and whether the physician ordered the appropriate level of care for the patient's condition. Increased Requests for Records as Demonstration Ends Although the demonstration ended in December, the RAC has until March to process many of the records. Hospitals in Florida had been overwhelmed with a sudden onslaught of record requests from HDI in late 2007. For example, one hospital reported that although they had received requests for about 5000 records since August 2005, they have received over 1100 record requests in the month of November alone.Another provider indicated that they have 7000 records currently in process with HDI.It is not feasible for a hospital to obtain, copy, and submit such large numbers of records in a reasonable period of time.It is also not feasible that HDI, or any contractor, could review the increased number of records being requested from providers across Florida by the close of the demonstration. Additionally, the fiscal intermediaries and quality improvement organizations are likely to be overwhelmed by the number of resultant appeals and unable to process the appeals in a timely manner.