cms rac statement of work 2013 - appeal...

4/19/2013

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CMS RAC Statement of Work 2013

An Overview of Important Changes, as of April 2013

4/19/2013

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Page § 5

What’s Our Source?

Posted by RAC Monitor on 4-18-2013

Unpublished PDFs

Two PDFs and a map image

Part of a GSA Request for Quote

Offered to GSA Contractors only

Bid deadline was April 4?

Announce Awards: Unknown

4/19/2013

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WHY Do We Now Have FIVE RACs?

CMS separated FFS Recovery Audit functions

into those submitted to an A/B MAC versus

those submitted to DME MAC and Home

Health/Hospice MAC.

So... a new, fifth RAC, devoted to DME/HHH.

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4/19/2013

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RAC Statement of Work 2013 General Tasks Included

RACs must:

Perform Post payment review of all Medicare claim and provider types

(excluding DME/HHH) AND a review of claims/providers that show a "high

propensity for error" as shown in CERT and other CMS analysis measures.

Perform Prepay review, per the Prepayment Review Demonstration -- active

only when CMS has authority to use the RACs for this.

Support CMS at all level of appeals, including "taking party status" at the ALJ

level in at least 25% of cases reaching that level.

Share methods, algorithms and edits used to find errors, with CMS and the

MACs.

Perform "necessary provider outreach to notify provider[s]" of purpose, etc.

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4/19/2013

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RAC Statement of Work 2013 Transitions

What happens if there is a "new" RAC?

What about all that work you just did?

What if you issued denials...

...and appeals are still pending...

...when the new RAC takes over?

You still collect your fee for that work, right?

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4/19/2013

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WRONG ANSWER!What happens if there is a "new" RAC?

ANY REMAINING RECEIVABLES FOR A RAC

- DENIALS BEING APPEALED AT ANY REMAINING LEVEL -

WILL 'TRANSITION' TO THE NEW CONTRACTOR.

Therefore, existing RACs lose those fees.

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How long does it take to transition to a "new" RAC?

Transition plans must be presented.

Work stoppage could happen.

Stoppage could last 3 to 6 months.

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4/19/2013

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RAC Statement of Work 2013 New RAC Tasks

RACs are now asked to --

"identify and report LCDs"

... ones that may benefit from CMS evaluation

... because of being outdated, flawed, etc.

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4/19/2013

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RAC Statement of Work 2013 New RAC Tasks

RACs are now asked to --

"submit monthly appeals reports"

... this is a new requirement.

... how many times the MACs request records?

... how many times the MACs affirm appeals?

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4/19/2013

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RAC Statement of Work 2013 Geographic Regions

The previous SOW included an exception for claims

processed by Wisconsin Physician Services (WPS)

-- that exception is now gone?

-- presumably because the map has been redrawn?

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4/19/2013

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The Validation Process was moved and there are

three changes to note:

• must post a new issue to their website, but no longer

mentions having a separate page for such postings.

• must post "review type", added to all the other items.

• must allow sort by posting date, plus provider type.

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4/19/2013

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RAC Statement of Work 2013 Review Type Percentages

CMS "may now impose percentage requirements

[for RACs to review] by claim types"

-- not to LIMIT the amount of reviews

-- but to ADD claim types specified by CMS.

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4/19/2013

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RAC Statement of Work 2013 Preventing Overlap

CMS added ZPICs, PSCs, OIG, FBI, DOJ

• Now able to input claims into the master table

of exclusions

• To avoid claims being reviewed by multiple

agencies simultaneously.

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4/19/2013

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RAC Statement of Work 2013 Payment for Copies of Medical Records

The old SOW stated:

CMS might assign a maximum payment amount per

medical record to be paid for copying & postage for

delivery of medical records for ADRs.

Now, the Max is: $25.00 total per medical record.

(about 200 pages plus postage)

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4/19/2013

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RAC Statement of Work 2013 Time To Review Claims

Time Frame to conduct a Complex Review: 30 days

• Previously 60 days

• RAC loses their fee if they take longer without

permission from CMS.

• No limit on the extension(s)...

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4/19/2013

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RAC Statement of Work 2013 Communications

As before, must communicate results of:

• Complex Reviews - ALL

• Semi-automated -- ALL

• Automated -- Denials only

• No timeframes designated

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4/19/2013

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RAC Statement of Work 2013 Discussion Period

No changes to the Discussion Period.

Must request in writing

Within 30 days of MAC Demand Letter “and/or” Review

Results Letter from a RAC

NOTE: if a physician (employed by provider) requests to

speak to the CMD, then the request must be acted upon.

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4/19/2013

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RAC Statement of Work 2013 Determine Overpayment Amounts

CMS has added two new terms:

• Full Denial

• Partial Denial

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4/19/2013

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Full denials

• includes language that IP care was not necessary at

any time during the stay... does this mean that if a

time is visible where IP is not appropriate, then IP is

not available -- OR do they mean that IP was not

appropriate at any single point in time?

• what does "at any time during the admission"

mean?

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4/19/2013

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Partial denials

• the RAC decides what was reasonable and necessary (no

mention of the medical record) OR determine the correct code

for the service "described in the medical record."

• How do they determine the amount?

• THEY DON’T -- the MAC does...

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4/19/2013

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Partial denials

• the RAC notifies the MAC

• the MAC then adjusts the claim

• "preferably via the file-based mass adjustment process"

• At that point, only the difference is collected.

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4/19/2013

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RAC Statement of Work 2013 ID of Improper Payments on Prepayment Review

Page § 5

Prepayment Reviews

• Prepay reviews not included in previous SOW

• Reviews of either-or-both claims and providers

• RACs do NOT choose claims to review

• CMS chooses, MAC/FI/Carrier flag for prepay

• RACs review all those claims

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Page § 5

Prepayment Reviews

• medical records will be requested

• not clear if ADRs come from the MAC or the RAC

• There are NO limits to these ADRs.

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Page § 5

Prepayment Reviews

• RACs must complete their review and then

communicate results to the MAC within 30 days of

the day they receive documentation, so to comply

with payment regulations

(Claims Processing Manual Publication 100-04 Chapter 1, Section 80.3.3)

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Page § 5

Prepayment Reviews

• MACs pay or deny based on RAC review results

• No extensions will be granted to the RAC

• There is no Discussion period for these reviews

• Associated claims MAY be reviewed, per CMS

4/19/2013

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RAC Statement of Work 2013 Learning from Trends

Page § 5

Expectation

"Auditors are expected to review data provided by

appeals contractors to identify ongoing trends or

issues of vulnerability that may be applied to current

reviews or potential appeals."

4/19/2013

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RAC Statement of Work 2013 Contact with Journalists

A paragraph specifically restricting

RACs from responding to any and

all reporters for information about

the RAC Program.

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4/19/2013

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RAC Statement of Work 2013 Approved Issues List Webpage

The paragraph about a Medicare Recovery

Auditor webpage does not now include any

mention of a separate page to list all the

approved issues.

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4/19/2013

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Gerrymandered Map

Appears to be done by number

of claims available for review.

WPS Exception is no longer

included.

More analysis forthcoming...

Page § 7

RAC Statement of Work 2013 New State Map of Jurisdictions

4/19/2013

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1-800-680-6067

[email protected]

http://www.appealacademy.com

Do You Have

Any Questions??? ?Page § 24
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