RAC Restart How to Clean up your Old Denials

Agenda CMS Restarts Parts of the RAC Program How to Clean up your Old Denials – Through CMS’s statistical sampling opportunity 2

CMS Restarts Parts of the RAC Program CMS is restarting the controversial RAC Program Limited fashion Starts in August Medicare fee-for-service claim reviews 3

CMS Restarts Parts of the RAC Program Current RAC Auditors will conduct: – A limited number of automated reviews and – A small number of complex reviews on certain claims including, but not limited to: spinal fusions, outpatient therapy services, durable medical equipment, prosthetics, orthotics and supplies; and cosmetic procedures – The Recovery Auditors will not conduct any inpatient hospital patient status reviews during this limited restart period 4

How to Clean up your Old Denials Office of Medicare Hearings and Appeals (OMHA) announced a way to clear up the ALJ backlog Statistical Sampling Pilot Program If you have more than 250 claims subject to appeal CMS statistical sampling game If you meet all of the criteria and choose to participate, OMHA will assign an independent statistical expert to assist the Administrative Law Judge (ALJ) in “carrying out the statistical sampling in accordance with Medicare guidance.” 5

How to Clean up your Old Denials In cases in which an ALJ appeal has been filed: – 80% of the overpayment findings were reversed in favor of the provider The majority of the extrapolations also have been vacated because the “statistical expert” utilized by the auditor failed to actually produce a statistically valid random sample And they don’t have to…. 6

How to Clean up your Old Denials Chapter 8 of the Program Integrity Manual – Touches on the concepts of statistical sampling and extrapolation – Allows for a huge amount of latitude – Sampling can be flawed and there is nothing the provider can do about it 7

How to Clean up your Old Denials Should a provider wait and deal with the ALJ with an 80% win rate for the provider or face the flawed statistical sampling from CMS? The ALJ is independent, CMS is not, so who would you rather place your fate in? Depends on your circumstances, but most providers would be better off waiting for the ALJ 8

By Rebecca Corzine Tarr RN CPA Executive Vice President MedPerformance LLC Questions/Comments? 9

Rebecca Corzine Tarr Executive Vice President MedPerformance LLC MedPerformance.com (813)