NARCESSA CHESIL PROJECT OFFICER, RAC REGION C DIVISION OF RECOVERY AUDIT OPERATIONS CENTERS FOR MEDICARE & MEDICAID SERVICES Recovery Audit Contractor.

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Presentation transcript:

NARCESSA CHESIL PROJECT OFFICER, RAC REGION C DIVISION OF RECOVERY AUDIT OPERATIONS CENTERS FOR MEDICARE & MEDICAID SERVICES Recovery Audit Contractor (RAC) Program Review and Update

2 What is the Current Status of the Permanent RAC Program? The Tax Relief and Health Care Act of 2006, Section 302, required a permanent and nationwide RAC program by January 1, 2010  Provider outreach has occurred in every state  All RACs have data  All states are now eligible for review

FY 2009 Outreach Presentations Circle = State Outreach Sessions Square = National Presentations Triangle = Local Presentations (Green = Regional) 3

4 CMS RAC Review Phase-in Strategy as of 06/24/09  Automated Review- Black & White Issues (June 2009)  DRG Validation- complex review (Aug/Sep 2009)  Complex Review for coding errors (Aug/Sep 2009)  DME Medical Necessity Reviews – complex review (Fiscal year 2010)  Medical Necessity Reviews- complex review (Calendar year 2010)  Automated Review- Black & White Issues (August 2009)  DRG Validation- complex review (Oct/Nov 2009)  Complex Review for coding errors (Oct/Nov 2009)  DME Medical Necessity Reviews – complex review (Fiscal year 2010)  Medical Necessity Reviews- complex review (Calendar year 2010) Earliest possible dates for reviews in yellow/green states Earliest possible dates for reviews in blue states

5  Region A: Diversified Collection Services (DCS) o (Provider Portal/Issues Under Review)  Region B: CGI Federal o (Issues)  Region C: Connolly Healthcare o (Approved Issues)  Region D: HealthDataInsights (HDI) o (New Issues) Where are New Issues Posted?

6 Pharmacy Supply and Dispensing Fees Wheelchair Bundling Urological Bundling Blood Transfusions Bronchoscopy Services IV-Hydration Neulasta (Pegfilgrastim) Once in a Lifetime Procedures Untimed Codes Clinical Social Worker (CSW) Services Knee Orthotic Bundling Some New Issues

7 Issue Name: Wheelchair Bundling Description: Bundling guidelines for wheelchair bases and options/accessories indicate certain procedure codes are part of other procedure codes and, as a result, are not separately payable. Provider Type Affected: DME Date of Service: 10/01/ Open States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia Additional Information: Additional information can be found in the following manuals/publications: article_version=32&contractor_id=140 Example of A New Issue Posting

8 What about Rebilling?  Providers can re-bill for Inpatient Part B services, also known as ancillary services, but only for the services listed in the Benefit Policy Manual. That list can be found at: 102c06.pdf 102c06.pdf  Rebilling for any service will only be allowed if all claims processing and timeliness rules are met. The normal timely filing rules can be found at: m104c01.pdf m104c01.pdf

9 Appeal When Necessary  The appeals process for RAC denials is the same as the appeals process for Carrier/FI/MAC denials  Do not confuse the “RAC Discussion Period” with the appeals process  Appeals data from demonstration and going forward

10 CMS Contact Information  CMS RAC Website:  CMS RAC

11 Questions?

12 Questions:  Q. Please clarify the reason for discussion period and how the provider should include this in their process?  A. The RAC Auditors contact information will be on each demand letter and the provider would call them for discussion if there was clearly an error in the take back demand.  Q. Will interest begin at day 30 or day 41 from the date of the demand letter?  A. Interest will begin on day 30  Q. What process does the provider use to rebill Part B Ancillary services following the denial of a Part A claim.  A. See Slide 8 – Remember : Provider cannot rebill until claim adjustment is made or I/P claim is paid back.

13 Questions:  Q. Does CMS anticipate starting the complex reviews earlier than January 2010?  A. No  Q. Will CAH's be reimbursed for copying cost differently than PPS hospitals?  A. Yes, CAH’s will be reimbursed on their cost report. Copy cost is an allowable Medicare cost at.12 per copy. PPS hospitals will be reimbursed monthly.  Q. Can you confirm that all deductables and copays must be returned to the patient on claims identified for takeback?  A. Yes, the beneficiary will be notified after the claim has been recouped.