ATTACK of the RAC How to prepare and respond to RAC audits

Overview Current Status How to Prepare –Education –RAC Response Team –Independent Audit –Communication How to Respond –Documentation –Rebuttal –Appeals Process

Current Status in Virginia Region C –Contractor: Connolly –Subcontractor: Viant MAC Delay- Medicare Part A Current Negotiations- Medicare Part B –50 Day Countdown…

How to Prepare: Education Learn from colleagues, the Demonstration Project and other sources –Medical necessity –Coding errors –RAC Status Documents ( –OIG Work Plan –Connolly’s Identified Issues Education for physicians and staff –Focus on areas of known weaknesses

Demonstration Results

How to Prepare: Independent Audit Self Disclosure –Important to work with legal counsel Legal obligations Benefits and Consequences Process for Voluntary Refunds

How to Prepare: RAC Response Team Develop a RAC Response Team Now –Include members from all areas of risk –On-going duties Team responsible for entire RAC process –Assessing areas of risk –Keeping track of all record requests –Implementing compliance strategies –Handling all RAC reviews and appeals from start to finish –Key person for all RAC communications

RAC RESPONSE TEAM: Important Information to Track Number of claims requested, Number of denied claims, Date of reimbursement or recoupment by CMS, The amount of reimbursement recouped, All communications between the facility and RAC, Status of appeals, and Complete timelines

How to Prepare: Communication Provide Connolly with Your Practice’s Contact Information: ovider_contact_information.aspx ovider_contact_information.aspx Document Communications with Medicare Local Coverage Determinations and Other General Communications

How to Respond: RESPOND! Respond, Respond, Respond –No Response (or an untimely response) equals automatic denial and potential loss of right to appeal Time to Respond: must provide requested records within 45 days RAC Team should control this process Tracking Tools- Record Request Limits

How to Respond: Documentation Issue: Majority of RAC audits involve Medical Necessity Improve chart documentation Submit a COMPLETE copy of the medical record Self-assessment of the claim and the medical record before responding

How to Respond: Rebuttal Provider can rebut RAC’s initial determination –File with RAC within 15 days after receipt When to consider: New documentation to support the claim Not required Does NOT toll deadline for filing formal appeal

How to Respond: Formal Appeals Process 5 Levels (Medicare Appeals Process) –Redetermination –Reconsideration* –Administrative Law Judge Hearing –Medicare Appeals Council Review –Federal Court

Results of the Demonstration Percentage Appealed Percentage Favorable to Provider Percentage of Claims Overturned Connolly- Part A 9.9%51.6%5.1% Connolly- Part B 7.3%62.2%4.6% All RAC- Parts A & B 22.5%34.0%7.6% Viant: ???

To Appeal or Not to Appeal? Factors to Consider Cost of appeal Resources Implications Quality of documentation Clinical support Legal involvement Time

Formal Appeals Process: Timeline FI, carrier 60 days+14 day extension QIC 60-day time limit ALI 90-day time limit MAC 90-day time limit US District Court Last Level- No time limit Notice Letter 180 Days to File 60 Days to File Days 240 Days 150 Days 150 Days 60+ Days Days 120 Days to File

Formal Appeals Process: Appeal Strategies Advocate the Merits Treating Physician Rule Waiver of Liability Provider Without Fault Reopening Not Based on Good Cause Challenging the Statistics

Appeal Strategies: Advocating the Merits Not technically a “defense” Factual and legal arguments supporting payment –Prepare position paper Use qualified expert to confirm medical necessity

Appeal Strategies: Treating Physician Rule Medical necessity Treating physician is in the best position to judge Physician’s determination should be given more weight than RAC –RAC uses medical professionals who have never met or assessed the patient

Appeal Strategies: Waiver of Liability Medical Necessity Payment permitted if provider “did not know, and could not reasonably have been expected to know, that payment would not be made for such services” Tip: Maintain records of all communications with Medicare representatives –i.e. Overpayment claim overturned in past

Appeal Strategies: Provider Without Fault Medical Necessity Generally, provider considered to be without fault if: –Exercised reasonable care –Made full disclosure of all material facts –Had a reasonable basis for assuming payment was correct Considers various factors –Age, linguistic limitations, etc. Document phone calls, guidance from CMS or carrier

Appeal Strategies: Reopening Not Based on Good Cause RACs must adhere to regulatory timeframes for reopening initial determinations For Medicare generally: –Within 1 year – for any reason –Within 4 years – for good cause –No deadline if reliable evidence of fraud RAC limited 3-year look-back period –Only back to October 2007 Good Cause? –Limitation: 2009 CMS Transmittal

Appeal Strategies: Challenging the Statistics RACs may extrapolate in certain circumstances Must follow Medicare’s statistical guidelines Actual Overpayment v. Extrapolation –Use a third party expert to challenge the validity of the extrapolation

Conclusion Take steps to prepare NOW –Establish a RAC Team –Limit exposure- Education –Maintain adequate records Respond Appeals process –Deadlines and Defenses

Questions Patrick C. Devine, Jr Courtney A. Miller