Natalie Warf, CHP, CPC Privacy Administrator HCA Regulatory Compliance Support 1

 166 hospitals,168 outpatient centers and 400+ physician practices in 20 states and England  More than 40 facilities had some RAC activity ◦ Predominately in Florida  HDI – HealthData Insights  Facilities located in all 4 permanent program RAC regions 2

1. Organization is the Key 2. The “Rules” Change 3. Track, Trend & Report 4. Know the Process & Associated Timelines 5. Understand the RAC Recoupment Process 3

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 Senior Leader ◦ CFO, CEO  Responsibilities ◦ Provide strategic priority and direction for RAC program ◦ Understand the overall RAC impact to facility  Financial  Staffing and productivity  ROI contracts ◦ Ensure the facility is ready and responding out of the gate ◦ Designate the facility RAC liaison 5

 RAC “Liaison” or “Coordinator” ◦ Designated by senior leadership ◦ Over all types of government audits? RACs, MICs…  Responsibilities ◦ Ownership and coordination of facility RAC activity ◦ Tracks timeliness ◦ Oversees the logging/tracking mechanism ◦ Leads the RAC team ◦ The RAC “go to” person  Potential candidates ◦ HIM Director ◦ Case Manager 6

 Ensure all affected areas in the loop ◦ Case Management ◦ HIM ◦ Physician Advisor ◦ Billing Office ◦ Mailroom ◦ RAC Liaison ◦ Senior Leadership ◦ Medical director ◦ Staff physician ◦ Outpatient entities 7

 Internal communication plan ◦ General RAC awareness ◦ Areas of responsibility ◦ Escalation process  External communication plan ◦ Know your contacts and develop relationships, when applicable  The RAC, CMS Project Officers, FI/MAC, QIC  Region C CMS PO: 8

 Liaison between CMS and the RAC  Grant extensions to the RAC  Approve RAC sample letters  Receives copies of provider dissatisfaction letters/correspondence  Suppresses or excludes claims  Approves all web-based applications 9

 Can work well for a chain or health system  May reduce cost and increase accountability  Potential functions for centralization– whatever works for your system ◦ All correspondence logged and processed ◦ Appeals prepared, sent and tracked  Centralize by type: coding vs. medical necessity ◦ Account follow-up performed  Single facility may centralize to a person or department 10

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 What is it? ◦ RAC Contract Requirements  Where is it found? ◦ CMS Website or FedBizOpps  What’s in it for you? ◦ Guides you on whether the RAC is following the “rules”  Examples ◦ Coding experts ◦ External validation ◦ Provider outreach ◦ Look back period ◦ Medical record limits ◦ Standardized letters ◦ Contingency fees ◦ Contractor websites ◦ Electronic records/submission 13

Provider TypeMedical Record Limit Part A Inpatient Hospital, IRF, SNF, Hospice 10% average monthly Medicare claims (max 200) per 45 days, per NPI Other Part A (Outpatient Hospital, Home Health) 1% average monthly Medicare services (max 200) per 45 days, per NPI Part B Solo Practitioner 10 medical records per 45 days Partnership of 2-5 individuals 20 medical records per 45 days Group of 6-15 individuals 30 medical records per 45 days Large Group (16+ individuals) 50 medical records per 45 days Other Part B Billers (DME, Lab) 1% average monthly Medicare services per 45 days *Expected to change in 2010 – TAX ID based instead of NPI driven

 CMS Main RAC Website: ◦  FedBizOpps Website: ◦ ◦ Use this site to view contract information ◦ Federal website providing government contracting opportunities 15

 Participate in advocacy groups  Work with the THA/THIMA  Provide data to the AHA by using RACTrac ◦  Attend provider outreach sessions  Contact the RAC or CMS project officer when you have problems  Complete provider satisfaction surveys 16

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 Monitor RAC websites for new issues ◦ Automated reviews  Verify appropriate billing edits in place and working  Work with your billing vendor to create/enhance edits  Examples: Blood Transfusions, IV Hydration ◦ Complex reviews  Ensure proper procedures in place  Case management for one day stay  Documentation guidelines followed  Know your weak spots 18

 Use a tracking tool ◦ External vendors ◦ In-house created database ◦ Centralized spreadsheet  Consider one person for data entry  Suggested data to track (account level detail) ◦ Dates correspondence received and sent ◦ Standardized denial reasons ◦ Appeal activity (dates, outcomes) ◦ Financials  More data tracked = better reporting 19

 Review data for trends ◦ DRG  Most reviewed?  Change rate? ◦ Discharge Status  Common issues? ◦ Medical Necessity  Documentation issues? Specific provider?  Process improvements needed?  Appeals data ◦ Consistently overturning RAC denials on appeal? ◦ Calculate success rates 20

 Senior Management  Summarize high level, appeal status, takebacks, dollars at risk  RAC Team  Deadline statistics, hot review items, frequencies of reviews, appeal statistics  Medical Staff  Top reviewed DRGs, medical necessity, denial rates  Appeals/Billing Staff  Accounts for follow-up (e.g., medical records, appeals)  Advocacy Reporting (e.g., AHA RACTrac)  Use to educate and improve processes/outcomes 21

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 CMS approves RAC issue  The RAC uses data mining and internal processes to identify improper payments  The RAC issues a demand letter  The FI/MAC/Carrier issues a remittance advice  The provider may ◦ Agree ◦ Discuss the issue with the RAC ◦ Submit a rebuttal or appeal 23

 CMS approves RAC issue  The RAC issues a medical record request  Provider submits records  The RAC reviews and sends ◦ Review Results Letter ◦ Demand Letter  The FI/MAC/Carrier issues an RA  The provider may ◦ Agree ◦ Discuss the issue with the RAC ◦ Submit a rebuttal or appeal 24

LevelsLevel One Redetermination Level Two Reconsideration Level ThreeLevel FourCivil Action ContractorFI/MAC/CarrierQualified Independent Contractor (QIC) Administrative Law Judge (ALJ) Departmental Appeals Board (DAB) U.S. District Court Provider Must Appeal Within: 120 days from RAC determination 180 days from FI/MAC determination 60 days from QIC determination 60 days from ALJ decision 60 days from DAB decision Contractor Response: 60 days 90 days 25 Medical records due in 45 days The RAC must respond to records in 60 days

 Review RAC decision  Don’t assume the RAC is “right”  Do them timely  Don’t forget the basics to avoid dismissals ◦ Dismissal = required elements missing from appeal ◦ Beneficiary Name, HIC #, Dates of Service, Item/Service appealed, and name and signature of appellant  Justify – cite Interqual® or Milliman® 26

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 Definitions o Recoupment and offset = Medicare takes the money due for an overpayment by deducting it from another RA o Remark code = Informational designation on a Medicare RA that provides clarification on the status of the claim o Remark Code N432 = Adjustment based on a Recovery Audit  Tells the provider the claim was adjusted due to a RAC review 28

 RAC demand letter and RA with remark code N432 by FI/MAC are issued  This starts the appeals and recoupment clock!  Use this to reconcile RAC activity  Recoupment will begin day 41 if a valid first level appeal is not received by day 30 at FI/MAC  Provider pays interest if auto-recouped on day 41  Recoupments are held if valid appeal received by day 30 for level 1 appeal or day 60 for level 2 appeal  Level 3 and higher appeals do not stop the takeback 29

 Review the Limitation on Recoupment final rule  Determine if the facility can meet a 30 day 1 st level appeal turnaround  Billing office should be on the look-out  Reconcile data  Interest ◦ Continues to accrue even if held and must be repaid if appeal not favorable ◦ Refunded to provider if denial overturned ◦ Rate set quarterly by Treasury Dept 30

Thank you! 31