Last year was the first full year of Medicare's nationwide recovery audit contractor program. Here Lori Brocato, audit management product manager for Healthport, makes five points on how it went.
1. Volume of requests lower than expected. Across all four RACs, the volume of document requests in 2010 was lower than expected. Levels were well below volume of requests in the RAC demonstration program, which had no volume ceilings. The full program has a ceiling, but in healthcare reform experience, RAC requests are not anywhere near those levels, even as CMS is expected to increase the ceiling this year.
2. Agreeing to change decisions. RACs are open to adjusting the allowable DRG. When the hospital contests RACs determination, it has often been able to persuade the RAC to accept a higher-paying DRG, although usually not as high as the hospital initially claimed. Ms. Brocato says this kind of "partially favorable decision" happens quite often. It is usually granted during the pre-appeal process, when RACs allow a discussion period with hospitals about a decision.
3. Failure to meet deadlines. RACs are supposed to have 60 days to respond to hospitals after records sent to them, but they have been routinely exceeding that deadline, taking as long as twice the allowed time. CMS officials are not penalizing RACs for this, saying the 60-day limit is more of a guideline and not a hard-and-fast rule, but they have added that a high number of missed deadlines might be considered in contract renewals with RACs.
4. Spotty reimbursement for sending records. RACs should be paying 12 cents a page plus the cost of first-class postage for all documents they request, but in many cases they only pay for the documents they used. They also don't pay for copying and sending back their request letter, even though this is a requirement. These are extensive amounts of records that often exceed the Post Office's 13-ounce limit for first-class packages, so they have to be sent by costly priority mail. A CMS official overseeing two of the RACs (DCS and CGI) said reimbursing copying and postage is up to each RAC to decide.
5. Reviewing the same item for multiple violations. RACs were not supposed to be able to review the same claim for multiple problems, such as determination of medical necessity and deciding whether the right DRG was used. If the RAC decides to recoup the whole payment based on medical necessity, then deciding the DRG level was too high would force the hospital to pay back more than it claimed. However, CMS said in an FAQ that RACs can review the same item for multiple violations.
Learn more about Healthport.
1. Volume of requests lower than expected. Across all four RACs, the volume of document requests in 2010 was lower than expected. Levels were well below volume of requests in the RAC demonstration program, which had no volume ceilings. The full program has a ceiling, but in healthcare reform experience, RAC requests are not anywhere near those levels, even as CMS is expected to increase the ceiling this year.
2. Agreeing to change decisions. RACs are open to adjusting the allowable DRG. When the hospital contests RACs determination, it has often been able to persuade the RAC to accept a higher-paying DRG, although usually not as high as the hospital initially claimed. Ms. Brocato says this kind of "partially favorable decision" happens quite often. It is usually granted during the pre-appeal process, when RACs allow a discussion period with hospitals about a decision.
3. Failure to meet deadlines. RACs are supposed to have 60 days to respond to hospitals after records sent to them, but they have been routinely exceeding that deadline, taking as long as twice the allowed time. CMS officials are not penalizing RACs for this, saying the 60-day limit is more of a guideline and not a hard-and-fast rule, but they have added that a high number of missed deadlines might be considered in contract renewals with RACs.
4. Spotty reimbursement for sending records. RACs should be paying 12 cents a page plus the cost of first-class postage for all documents they request, but in many cases they only pay for the documents they used. They also don't pay for copying and sending back their request letter, even though this is a requirement. These are extensive amounts of records that often exceed the Post Office's 13-ounce limit for first-class packages, so they have to be sent by costly priority mail. A CMS official overseeing two of the RACs (DCS and CGI) said reimbursing copying and postage is up to each RAC to decide.
5. Reviewing the same item for multiple violations. RACs were not supposed to be able to review the same claim for multiple problems, such as determination of medical necessity and deciding whether the right DRG was used. If the RAC decides to recoup the whole payment based on medical necessity, then deciding the DRG level was too high would force the hospital to pay back more than it claimed. However, CMS said in an FAQ that RACs can review the same item for multiple violations.
Learn more about Healthport.