1. Medicare Recovery Audit Contractor (RAC) Program Jennifer Amann, MBA Healthcare Resource Providers, LLC

2. Recovery Audit Contractors Goal: Identify overpayments and underpayments made by CMS to providers Four contractors hired by Medicare to conduct audits –Regional rollout started in March 2009 –Scheduled to involve all 50 states by 2010 Paid based on “savings” to Medicare program –Incentive to find incorrect overpayments

4. RAC Contractors Diversified Collection Services, Inc. (A) –www.dcsrac.com www.dcsrac.com CGI Technologies and Solutions, Inc. (B) –www.racb.cgi.com www.racb.cgi.com Connolly Consulting Associates, Inc. (C) –www.connollyhealthcare.com www.connollyhealthcare.com HealthDataInsights (D) –www.racinfo.healthdatainsights.com www.racinfo.healthdatainsights.com

5. RAC Websites Sample audit request letters List of approved issues for review –Example: Diversified Collection Services 7 Inpatient hospital issues (most DRG related) 11 DME 1 Ambulance providers 1 Clinical social workers (CSW) –Detailed descriptions and policy-related links provided Radiology procedures currently most likely to be pulled in from inpatient hospital issues

6. Medical Record Review RACs must have a physician medical director and certified coders –Must provide credentials upon request No audits on claims paid before 10/1/2007 –Limited to 3-year retrospective review CMS sets limits per year –Covers the number of medical records that can be requested per 45-day period

7. Medical Record Review Limitations 2009 limits for Part B providers –10 records for solo practitioners –20 for 2-5 physicians –30 for 6 -15 physicians –50 for groups of 16 or more Number of records can be adjusted annually –No updates for 2010 published yet

8. RAC Letters Specify coverage, coding or payment policy violated Reason for review Description of overpayment situation Recommended corrective actions Explanation of: –Provider’s right to submit a rebuttal statement prior to recoupment of overpayments –Procedures for recovery of overpayments –Right to request extended repayment schedule –Right to appeal –Other requirements for written notifications

9. Audit Process Typically practices will receive letters requesting medical records Auditors have authority to go on site to view and copy records –Practices can refuse access, however –RAC then needs to provide written request for copies

10. Educational Resources Watch for RAC contractor outreach activities –Several have scheduled presentations at industry association meetings CMS has announced series of free educational teleconferences –April 28, 2010 RAC 101 –May 12, 2010 RAC 101 for Physicians –Calls scheduled 1:00 – 2:30 EST 877-251-0301

11. Preparing for the RAC What were the results of recent CERT audits? Track coding and medical necessity denials for patterns Conduct internal coding audits –What was ordered was what was done –What was done was what was billed –What was billed was what was paid

12. The Bigger Picture Overall Medicare auditing/enforcement actions –CERT –ZPIC (Medicare Zone Program Integrity Contractors) –RAC ZPIC compliance efforts (assigned based on MAC jurisdictions) –Data analysis and data mining –Medicare reviews to support “benefit integrity” –Supporting law enforcement and answering complaints –Investigating fraud and abuse –Recommending recovery of Federal funds through administrative action –Referring cases to law enforcement

13. Thank you! Jennifer Amann, MBA Healthcare Resource Providers, LLC P.O. Box 90190 Albuquerque, NM 87199 Cell:817-406-3355 jkroken@radconsultants.com www.radconsultants.com