In compliance... with a RAC audit

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• Publié par: Mothug
• Nombre de lectures: 23
• Langue: English

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In compliance...
with a RAC audit
by Debra Mariani, CPC, Practice Affairs Associate, Division of Advocacy and Health Policy
edicare providers should prepare for the entire staff needs to be made aware of such letters.
Recovery Audit Contractors (RACs) to The point person most likely will be the practice’s Mcontinue with their original plan for com- compliance officer. The team may include mem-
pleting audits, now that the protest of the award of bers from several areas of the practice, including
the RAC’s contract has been resolved. The Febru- finance, health information management, medical
ary 4 settlement means that the stop-work order records, case management, and, most importantly,
has been lifted, and the Centers for Medicare & the physician. Even surgeons who have small offices
Medicaid Services (CMS) will now proceed with should educate their staff and appoint one person
the implementation of the RAC program. This to handle all areas of the RAC audits, denials, and
article can be used as a tool to help surgeons and demand letters. The most important piece of in-
office staff to handle and prepare for an audit and formation the staff needs is what to do when this
as a description of the process for appealing a RAC letter arrives. The RAC team should have policies
audit determination. in place for receiving, responding to, and following
up with a RAC letter. If these policies are not in
Things to consider place, surgeons may lose any opportunity to over-
RACs choose issues to review based on data- turn improper RAC determinations.
mining techniques. Data mining is a process Keep in mind that there is a limit to the number
designed to explore data in search of consistent of medical records the RAC can request: 10 for a
patterns and/or systematic relationships between solo practitioner, 20 for a partnership of two to five
variables and then to validate the findings by individuals, 30 for a group of six to 15 individuals,
applying the detected patterns to new subsets and 50 for a large group of 16-plus physicians.
of data. For example, with automated reviewing, Once a practice receives a letter, the staff has 45
the RAC will be able to make an overpayment or days to respond. If a practice stores its medical
underpayment determination without reviewing records off-site, a policy should be in effect for
medical records. To be aware of areas of pos- retrieving these records quickly.
sible audits, surgeons should stay abreast of the Key senior personnel should gather facts that
information in Office of the Inspector General will help to ensure that the practice is submitting
(OIG) (www.oig.hhs.gov/publications/docs/work claims appropriately. Some internal audits may be
plan/2009/WorkPlanFY2009.pdf), Comprehensive a key factor in finding mistakes. In some cases, an
Error Rate Testing (CERT) (www.ngsmedicare. external company can come in to do an audit of
com/ngsmedicare/DMEMAC/ReviewProcess/ documentation and billing practices. All education
CERT/IndexCertDMEMAC.aspx), and Govern- and compliance issues should be documented and
ment Accountability Office (GAO) (www.gao.gov) corrected to show that the practice is striving for
reports. New issues will be posted on the RAC Web compliance with all billing and coding practices.
site (www.cms.hhs.gov/RAC). The audits can go One of the biggest problems found by RACs so
back three years from the date the claim was paid, far is improper diagnosis coding. This problem
although RACs will not review claims submitted could be avoided by clearly documenting the pa-
before October 1, 2007. tient’s diagnosis or the procedure’s medical neces-
One of the most important steps a surgeon can sity. Duplicate payment for a service is another
take in dealing with a RAC audit is to build a strong area of concern. Surgical offices should have a
response team. This group of allies should assign policy in place to make sure that when a duplicate
a point person to set up an organized operating payment is received, the carrier is contacted for
system for handling the medical record request further instructions. All calls and instructions
letters from the RAC. To accomplish this task, the should be documented.
36
VOLUME 94, NUMBER 5, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONSAppeals process for RAC audits 3. At the third level (administrative law judge,
The same appeal policies that would be used or ALJ, hearing) of the appeal process, which is
for Medicare claims (Medicare Part A and Part B the most formal form of appeal before a court
appeals process) apply to the RAC audit decisions. date, the provider may request a hearing before
All providers may appeal any determination made an ALJ by filing the request in writing with the
by the RAC auditors. There is the informal appeal entity specified in the notice within 60 days of
process and a formal appeal process. receipt of the QIC’s reconsideration notice.
• Informal process a. Oral testimony will be required.
1. Providers can submit an appeal directly to b. CMS and/or the fiscal intermediary may
the RAC within 15 days of receiving a notice to be requested to participate.
recoup an overpayment. This step is optional and c. The ALJ has 90 days from the date the
not included in the five-level appeal processes hearing request is received.
described later in this article. d. This decision is binding unless it is modi-
2. The RAC considers the appeal to determine fied or reversed by the Medicare Appeals Council.
whether its decision is justified. e. The request must meet an amount in
• Formal process controversy of at least $120.
The chart on page 38 depicts the formal appeal 4. At the fourth level (Medicare Appeals Coun-
process. cil) of the appeal process, the provider can file a
1. At the first level (redetermination) of the request for review with the MAC within 60 days
process, an appeal can be requested in writing of receipt of the ALJ’s decision.
within 120 days of initial determination (from a. The MAC may review the ALJ’s decision.
the RAC) to the fiscal intermediary (or carrier or b. No appearance is required at this proceed-
Medicare administrative contractor that usually ing and there are no minimum requirements for
pays claims). the amount in controversy.
a. The fiscal intermediary will have 60 days c. The Medicare Appeals Council has au-
to determine whether the RAC’s findings are justi- thority to modify, reverse, or remand the case back
fied. to the ALJ.
b. If the appealed claim is overturned, the d. The MAC must issue a determination
fiscal intermediary will include appropriate pay- within 90 days of reviewing the ALJ’s decision.
ment with the redetermination letter. If the MAC cannot make a decision within the
c. If the appeal is denied the fiscal intermedi- 90 days, it will inform the appellant of the right
ary will provide a written explanation. to move this decision to the federal district for
2. At the second level (reconsideration) of the judicial review.
appeal process, the provider may ask for recon- 5. At the fifth level (U.S. District Court) of the
sideration in writing for a review by a qualified appeal process, the provider must file a lawsuit in
independent contractor (QIC) if the fiscal inter- the federal district court within 60 days of receipt
mediary renders an unfavorable decision. of the Medicare Appeals Council decision.
a. Physicians have 180 days to file a request a. Evidence presented at this level is limited
for reconsideration. to the administrative record.
b. This request must be on a standard CMS b. The Secretary of the U.S. Department
form (go to http://www.medicare.gov/Basics/forms/ of Health and Human Services is named as the
default.asp) or the reconsideration request form defendant.
that comes with the fiscal intermediary redeter- c. The minimum amount in controversy at
mination letter. this level must be at least $1,220 (for 2009).
c. In this appeal, it is vital that the request
be accompanied by all concerns, issues, and evi- To consider before appealing a RAC decision
dence to support the appeal. 1. Is there clear documentation guidance from
d. During this level of appeal, appearance Medicare to support or rebut the determination?
by the surgeon and his or her staff is optional. 2. Does the documentation meet the CMS
e. The QIC has 60 days to make its decision. guidelines?
37
MAY 2009 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONSFigure: Comparison of former and current 1869 fee-for-service appeals
3. Should legal counsel be involved? 4. Surgeons who are appealing audits may want
4. Does the cost of the appeal outweigh the to hire a legal defense to support medical judgment
benefits? and documentation.
Once a provider appeals a decision, the RAC
To prepare for appealing audit determinations must stop pursuing the claim. Interest continues
1. List the factual and legal arguments for sup- to accrue throughout the appeal process.
port of payment; this may consist of illustrations, In summary, your best offense is an educated
medical summaries, graphs, or any other materials office that understands the issues regarding the
that support the appeal and should be easy for the RAC, including determining what role office staff
decision makers to understand. plays in handling time-sensitive information and
2. Documentation should be supported by the knowing your time l