the recovery audit contractor (rac) and …€¦ · the recovery audit contractor (rac) and...

The Recovery Audit Contractor (RAC)

and

Comprehensive Error Rate Testing

(CERT)

POEA0621 (09/2010)

2 National Government Services, Inc.

Today’s Presenters

Provider Outreach & Education Consultants

• Linda Teti, CPC

• Donna Pisani

• Carlette Murray, CPC

3 National Government Services, Inc.3

Disclaimer

National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies, and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.gov.


CERT Agenda

• CERT Background

• CERT Process

• CERT Goals

• National CERT Data

• Common Errors

• Helpful Hints


RAC Agenda

• Brief history and discussion of RAC program

• National Government Services’ role in RAC

• Suggestions for success when audited

5


Objectives

• Provide an overview of both the CERT and RAC programs to give you a better understanding of how they relate to your Medicare Part B billing.


Acronyms

ABN Advanced Beneficiary Notice of NoncoverageCERT Comprehensive Error Rate TestingCDC CERT documentation contractorCRC CERT review contractorE&M Evaluation & ManagementEFT Electronic funds transferEMR Electronic medical recordsFI Fiscal intermediaryLCD Local coverage determinationMAC Medicare administrative contractorMLN Medicare Learning NetworkQIC Qualified independent contractorOIG Office of Inspector GeneralRAC Recovery audit contractor


Did You Know?

• Medicare receives over 1.2 billion claims per year

• This equates to

– 4.5 million claims per work day

– 574,000 claims per hour

– 9,579 claims per minute

Comprehensive Error Rate

Testing (CERT)


Comprehensive Error Rate Testing

• Began 2002

• First reports November 2003

• Fee-for-service only

• Determine a National Error Rate

• Measure of contractor performance

• Local, Regional, and National Error Rate Patterns


CERT Contractors

• CERT Documentation Contractor (CDC)

– The CDC, located in Maryland, is responsible for requesting and obtaining documentation to support the payments for the selected claims.

• CERT Review Contractor (CRC)

– The CRC, located in Virginia, is responsible for reviewing the submitted documentation to determine if Medicare payment was supported


CERT Process

• Randomly select sample of claims

• Request medical records from the billing provider

• Review claims along with medical records

• Determine if the claim or service is billed in error

• Appeal Rights

• Produce Reports


Review

• CERT reviews according to:

– Local coverage determination (LCDs)

– National coverage determination (NCDs)

– Medicare coverage regulations


Goals

• CMS Goals for CERT

– Reduce National Medicare Fee-for-Service Paid Claims Error Rate

– Decrease Contractor Specific Paid Claims Error Rate

• Providers/Suppliers

– Reduce unnecessary denials


November 2009 Improper

Medicare Fee-for-Service Payments Report

• Released February 5, 2010

– Claims received between April 1, 2008 and March 31, 2009

– http://www.cms.hhs.gov/cert/

– No Contractor Specific Data

– National Paid Claims Error Rate –

• 7.8%/$24.1B


Improvements to the

CERT Process

• Modifications made to the CERT medical review criteria:– February 23, 2009 - CMS directed the CERT contractor that clinical

review judgment cannot override statutory, regulatory, ruling, national coverage decision or local coverage decision provisionsand that all documentation and policy requirements must be met before clinical review judgment applies.

– May 31, 2009 - Based on CMS policy, during the course of a complex medical review, a claim must be denied if the signature on the medical record is absent or illegible. Through their audit, OIG found that CMS contractors were not uniformly applying this policy. Thus, CMS provided guidance to the CERT contractor that claims should be counted as an error if the CERT reviewer could not identify the author of the medical record entry.


Error Categories

• No Documentation – Claims are placed in this category when the provider/supplier fails to respond to repeated attempts to obtain the medical

records in support of the claim

• Insufficient Documentation – Claims are placed into this category when the medical documentation submitted does not include pertinent patient facts

• Medically Unnecessary – Claims are placed into this category when claim review staff identify enough documentation in the medical records to make an informed decision that the services billed were not medically necessary based on Medicare Coverage Policies

• Incorrect Coding – Claims are placed into this category when providers submitted medical documentation support a lower or higher code than the code

submitted

• Other – This represents claims that do not fit into any other category (service not rendered)


Error Categories

• No Documentation – 0.1%

– Part B – 0.1% DME – 0.00% Part A – 0.0% Inpatient – 0.0%

• Insufficient Documentation – 1.9%


• Medically Unnecessary – 4.0%


• Incorrect Coding – 1.6%


• Other – 0.1%



Common Errors

• No Documentation – No medical record received

• Insufficient Documentation –– Physical Therapy - Documentation received included the initial

evaluation signed by the physical therapist. Missing were the order, and/or plan of care signed by the ordering physician and treatment notes.

– Missing or illegible signatures.

• Medically Unnecessary –– Inpatient Hospital Stay - Payment was made for a one day

inpatient hospital stay. The patient was admitted with a diagnosis of abdominal pain and stayed less than 12 hours. The patient failed to meet medical necessity criteria for an inpatient admission. Service could have been provided with the patient in an outpatient observation status.


Common Errors Cont.

• Incorrect Coding –– Payment was made for a transthoracic echocardiography with

contrast, real time, with exercise stress test. After reviewing the medical records submitted it was determined that the diagnostic study was performed without the use of contrast material, therefore, the procedure code was changed.

– Payment was made for initial nursing facility care, per day (99306) which requires three of three key components; comprehensive history, comprehensive exam and high complexity medical decision making. Upon review it was determined that the documentation supported a down code to 99304.


Common Errors Cont.

• Other –– Payment was made for a high level E&M service. The providers

office submitted a letter stating the patient was not seen by this physician on this date of service.

– Payment was made for outpatient radiation oncology therapy. Review of the documentation submitted and patient history it was revealed that the patient was in a covered inpatient stay for the billed dates of service.


Signature Requirements

• Signature Requirements for Medical Documentation– The use of stamped signatures is not

acceptable on any medical record

– Medicare requires a legible identifier for services provided and ordered

– Medicare will accept handwritten, electronic signatures or facsimiles of original written or electronic signatures for medical review purposes


Signature Requirements

• Signature Requirements for Medical Documentation– Providers using electronic systems should recognize that there is

a potential for misuse or abuse with alternate signature methods

– All state licensure and practice regulations continue to apply• Where state law is more restrictive than Medicare, the contractor

applies the state law as standard

• References – Signature Guidelines for Medical Review Purposes

• CR # 6698/MM 6698 Revised –Effective Date March 1, 2010 –Implementation Date April 16, 2010

• Related CR Transmittal #: R327PI

– CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1


Suggested Documentation

for E&M Services

• Provider progress notes & orders

• All orders for labs/tests/results etc.

• Documentation to support all additional services billed on claim



for Physical Therapy Services

• Initial/Re-evaluations

• Treatment Plan/Plan of Care (M.D. Certified)

• Treatment logs/notes (include treatment time for timed modalities)



for Lab Services

• Lab, Diagnostic and Therapeutic Procedures need one of the following showing physician intent and medical necessity:

– Order or requisition form with physician signature and diagnoses that necessitate the services rendered

– An electronic mail by the treating physician/practitioner or his/her office to the testing facility (include diagnoses)

– Screen print of electronic request by the physician.



for Lab Services Cont.

– With electronic system requests, also include diagnoses and one of the following:

• Copy of your protocol with requirement of physician logon ID and password to order the tests or procedures (Protocol can be sent once per provider.)

• Evidence of physician entry into the request system with individual logon ID and password such as audit trail that proves the doctor entered the request for services electronically

• Physician progress note of visit in which procedure was ordered or the visit following the test procedures showing physician’s signature and medical necessity

• Physician signature and diagnoses on test results



for DME Items

• Written physician order

• Certification Of Medical Necessity (CMN) when applicable

• Documentation from the medical records of the ordering physician or other healthcare professional



for Skilled Nursing Facility Services

• To support the RUGS level billed, be sure to send in:

– All medication administration

– Therapy treatment records with number of minutes

– The MDS look back period (if this is during the hospital stay, it is still the billing providers responsibility to obtain and submit this documentation).


Important Notes

• Please be sure documentation submitted is legible along with a legible physician signature or service will be denied

• Please submit records for all dates of service on the claim

• Please ensure that the medical records submitted provide proof that the service's was rendered and justification to support the medical necessity


Submitting Documentation

• Not a violation of the HIPAA Privacy Rule

• Bar code cover sheet/CID #

– Preferred method of submitting records is via fax number 240-568-6222


Overnight Mail Option

CERT Documentation Contractor

Attn CID #: XXXXXX

Suite 9

9090 Junction Drive

Annapolis Junction, MD 20701

Toll-free number: 888-779-7477


Additional Resources

• www.cms.hhs.gov/cert

– CERT information and CERT published reports

• www.certprovider.com

– CERT newsletters, CERT sample letters, and provider address directory

The Recovery Audit

Contractor (RAC)





Mission of a Recovery Audit

Contractor

• The RACs are contracted by CMS to detect and correct past improper

payments made on Health Care Claims.

• The goal is to help CMS and it’s MAC’s, FI’s and Carriers implement actions that will prevent future improper payments.


Will the Recovery Audit

Contractors Affect Me?

• Yes, if you submit claims to Medicare fee-for-service contractors, your claims are subject to review by the RAC

– RACs are not reviewing claims under a Medicare Advantage plan


The RAC Review Process

• Two types of review

– Automated (no medical records needed)

– Complex (medical record required)



• RACs are bound by and reviewing

– Medicare policies

– NCD

– LCD

– Manual Instructions



• Issue selected for review

• CMS approves issue

• RAC requests claims

• RAC reviews documentation (complex review) or claim (automated review) and makes determination



• If an error is found, a file is sent to the claims processing contractor (MAC, FI, or Carrier) to be adjusted for over or underpayment.


Documentation

Limits – Capped

Two caps will exist in fiscal year 2010

1. Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers

2. From April–September 2010, will have a cap of 300 additional documentation requests per campus unit, per 45 days


When a Payment Determination Has

Been Issued

• When the RAC identifies an improper payment, they will issue a demand letter.

• If you agree with the determination, National Government Services will issue the recoupmentoffset on your remittance advice (unless you have submitted a check or a valid appeal).

• RAC recoupment offsets will be identified on your remittance advice with remark code message:

– N432: Adjustment based on recovery audit


Documentation

Limits – Capped

• Questions concerning the RAC documentation limits can be directed to [email protected]


Provider Options – RAC

Overpayment Determinations


The Collection Process

• Carriers, FIs, and MACs issue remittance advice

– Remark Code N432: Adjustment Based on Recovery Audit

• Demand letters sent by the RAC

– Discussion period begins

– Appeals timeline starts


The Collection Process

• Carrier, FI, and MAC recoups by offset unless

– Provider has paid in full

– Submits a valid appeal by day 30


Remittance Advice

• Remark code N432–Adjustment based on recovery audit

• Negative amount for the adjusted claim

• Positive amount on the summary page

• Electronic fund transfer (EFT) or check will balance with the amount paid on that remittance advice (RA)


When a RAC Demand

Letter is Received

• If you agree with the RAC’s determination you can:

– Repay the overpayment amount by check;

– Allow National Government Services to recoup the overpayment from future remittance payments; or

– Request or apply for an extended payment plan.

• If you do not agree with the RAC determination

– You may use the Medicare appeals process. Note that you must file an appeal within 120 days of the RAC determination.


Steps to Take in an

Overpayment Situation

• 15 days

– Providers have 15 days from the date of the demand letter to submit a rebuttal statement

– The rebuttal statement is not an appeal and will not stop recoupmentactivities

• The rebuttal period is a process by which a provider can request the FI, carrier, or MAC to review the recoupment amount


Steps to Take in an


• 30 days

– Contact the RAC immediately if you are unable to refund the entire amount

– Refund is due within 30 days from the date of the demand letter

• Can submit a check for the full refund

• Interest will begin on day 31 for each full 30-day period payment is not made on time

• Contact the RAC immediately if you have filed bankruptcy


Steps to Take in an


• 40 days

– If no payment has been made, Medicare will begin withholding on day 41

• The withholding of Medicare payments will apply to current and future claims until the full overpayment amount and any applicable interest has been recouped or an acceptable extended repayment request is received


A Provider May

Stop Recoupment

• If Medicare receives a valid and timely request for a redetermination within 30 days from the date of the demand letter

– If the appeal is filed later than 30 days, recoupment will stop at whatever point that an appeal is received

• Medicare may not refund any recoupment already taken


A Provider May

Stop Recoupment

• If an unfavorable or partially favorable redetermination decision is made on appeal, the provider decides to file a valid reconsideration with the qualified independent contractor (QIC)


Provider Options

for Repayment

• Pay by check

• Allow recoupment from future payments

• Request or apply for extended repayment plan


Tips When an Overpayment Occurs

• Send claim details with checks

– Send the RAC-related checks to the RAC lockbox

• Keep track of RA

• RAC tracking tools

• Communicate with the RAC

• Communicate with the FI, carrier, or MAC


Appeal When Necessary

• The appeal process for RAC denials is the same as the appeal process for carrier, FI, or MAC denials

– If you disagree with the RAC determination

• Take advantage of the RAC discussion period

• File appeal before the 120th day after the demand letter

– File within 30 days of demand letter to stop recoupmentof funds



Appeals Chart

Appeal Level Time Limit For Filing Monetary Threshold

Redetermination 120 days from date of receipt of RA

None

QIC Reconsideration

180 days from redetermination notice

None

ALJ

Hearing

60 days from reconsideration notice

$120 *

DAB Review 60 days from

the ALJ decision

None * (Providers are unable to proceed to the next level unless he amount in controversy is $1,

220 or more)

Judicial Review 60 days from DAB decision

$1,220 *


Appeals Process


Successful Appeals

• Provider is reimbursed for covered items/services

– Any recouped funds and interest paid will be repaid to the provider


RAC Contact Information

RAC Address Phone Web Site E-mailDiversified Collection Services (DCS)

Region A (VT, NH, ME, MA, RI, CT, NY, NJ, DE, MD, DC, PA)

333 North Canyons Parkway, Ste 100

Livermore, CA 94551-7661

(866) 201-0580 www.dcsrac.com [email protected]

CGI TechnologiesRegion B (MN, WI, MI, OH, IN, IL, KY)

11325 Random Hills Rd

Fairfax, VA 22030-6051

(877) 316-7222 http://racb.cgi.com [email protected]


RAC Contact Information

RAC Address Phone Web Site E-mailConnolly ConsultingRegion C (WV, VA, TN, NC, SC, GA, AL, MS, FL, AR, LA, TX, OK, NM, CO)

50 Danbury Rd

Wilton, CT 06897

(866) 360-2507 www.connollyhealthcare.com

[email protected]

HealthDataInsightsRegion D (WA, OR, ID, MT, ND, SD, WY, UT, NE, IA, KS, MO, CA, NV, AZ, HI, AK)

7501 Trinity Peak St, Suite 120

Las Vegas, NV 89128-6896

(866) 590-5598 Part A

(866) 376-2319 Part B

https://racinfo.healthdatainsights.com

[email protected]

Significant Facts for

Successful Medicare Billing


New Claim Filing Time LimitsEffective 01/01/2010

• Regulations changed by Patient Protection and Affordable Care Act (PPACA)

– New one-year timely filing rule, based on date of service

– Medicare Part A & Part B Fee-For-Service claims

– Permission in law to allow exceptions to one-year filing deadline

• No exceptions established at this time


New Claim Filing Time Limits

Services Rendered: Claim Filing Date

10/01/08 – 09/30/09 12/31/10

10/01/09 – 12/31/09 12/31/10

01/01/10 and after 1 calendar year from date of service


Claim Filing Rules

• Claims not submitted by time limit are provider-liable

• Beneficiary cannot be charged for provider-liable charges


Record Requests/Documentation Tips

• Respond to Additional Development Request (ADR) within 30 days

• Documentation– Legible

– Copy both sides

– Signatures

– Do not bind records together

– Do not highlight records

– Do not tab records

– Make sure the ADR request matches the records sent


Submitting Duplicate Claims:

• May delay payment– Resubmitting your claim prior to receiving a

determination not only increases administrative costs to the Medicare program but to you as well.

• Could cause you to be identified as an abusive biller; or may result in an investigation for fraud if a pattern of duplicate billing is identified– Although National Government Services does not

believe providers are trying to deliberately receive duplicate payment by submitting duplicate claims for one service we must remind providers that this is an inappropriate billing practice.


Avoid Duplicate Claims

• Allow 29 days for paper claims and 14 days for electronic claims to be processed

• Electronic Claims Submitters should:

– Check your EDI validation report to verify claims were received and accepted

– Check your software system to verify claims’ software system is not set up for automatic rebill every 30 days or at any other set time intervals

– Ensure that your claims batching process is functioning properly


Avoid Duplicate Claims

• Electronic and Paper Submitters should:– Access the Interactive Voice Response (IVR)

System to determine if a claim has been denied as a duplicate (CO-18)

– Pay close attention to your remittance advice to determine if the denied claim(s) should be resubmitted or appealed

– Make sure that your billing staff or third party billing service knows the Medicare payment floors and claims filing rules


What is Internet-Based PECOS?Easy – Fast - Secure

• Better way for physicians, nonphysicianpractitioners, and third-party staff who are authorized to:– Submit new initial enrollment record

– Make changes to existing enrollment record

– Add or change reassignment of benefits

– Reactivate enrollment

– Voluntarily withdraw enrollment

– Revalidate enrollment


New York Medicare/Medicaid

Crossovers

Effective December 3, 2009

• NY Medicaid has agreed to process Medicare crossover claims directly from Medicare's Coordination of Benefits Contractor, (COBC), Group Health Inc., (GHI), regardless of the claim's date of service.

• Remittance Remark Code MA 18 will indicate your claim has successfully crossed over to Medicaid.

• GHI, in its role as the COBC, will be sending crossover claims to New York Medicaid for all of New York State.

• Claims submitted by pharmacies for payment of the Part B drug coinsurance and deductible are excluded from the crossover system.


Medicare Crossover Reminders

• Allow sufficient time for the Medicare crossover process to work – Approximately 15 work days after Medicare’s

reimbursement is made, before attempting to balance bill your patients’ supplemental insurers as stated in MLN Matters Article SE0909. http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0909.pdf

• Do not balance bill until written confirmation from Medicare that your patients’ claims will not be crossed over is received, or you’ve received a special notification letter explaining why specified claims cannot be crossed over.


Medicare Crossover Reminders

• Crossover Issue:

– If your claims that cross over to NYS Medicaid are rejected by Medicaid because they are unable to identify the provider or do not have a provider agreement on file.

– Contact NYS Medicaid to have your provider information setup with Medicaid.

– NYS Medicaid Provider Enrollment: 800-342-3005


J13 Contact Information

Interactive Voice Response (IVR) 877-869-6504

Provider Contact Center 866-837-0241

Fax on Demand 866-709-1905

Electronic Data Interchange (EDI) 877-273-4334

Correspondence National Government Services

Part B Provider General Written Inquiries

P.O. Box 7052

Indianapolis, IN 46207-7052


Contacting the Telephone

Reopening Unit (TRU Line)

• TRU Line – 888-812-8905 - follow prompt• Part B TRU line hours of operation:

Monday - Friday, 8:00 a.m. to 3:00 p.m. (Eastern)• Faxes are accepted and representatives are permitted to accept

more than three claims per call• When calling TRU Line, provide the following information:

– Beneficiary’s Name

– Medicare Health Insurance Claim Number

– Your Full Name (first and last name)

– Your Phone Number

– Provider’s Name

– Provider’s Number

– Date(s) of Service in Question

– Reason for Request


Web Site Overview

• www.NGSMedicare.com

– Sign up for Listserv

– Read Medicare Monthly Review

– Obtain CMS and National Government Services forms

– Research LCDs and NCDs

– Refer to fee schedules

– Explore frequently asked questions (FAQs)

– Register for upcoming trainings and download materials

– Take computer-based trainings (CBTs)


National Government Services Event

Calendar and Contact Information

• Visit our Web site at www.NGSMedicare.com– Choose Part A (Business Type) and your state

(Region) and select “Go.”

– Accept CPT/HCPCS code attestation

• To view Events Calendar, select “Calendar of Events” under the Education and Support category (on dark blue navigation bar).

• To view Contact Information, select “Contact Information” under the Resources category (on dark blue navigation bar).


We Need to Hear From You!

• Survey presents when using the NGSMedicare.com Web site

– We look at survey scores every day

– We read every comment our users submit

– We use scores and comments to develop plans to improve the Web site

• We need to hear from more of you more often!


Web Site Survey

• If you have never completed the survey:

– Please do so the next time it is presented

• If you have completed the survey before:

– Thank you!

– Please complete it again to tell us how recent changes have impacted your experience


Web Site Survey

• This is your chance to have your voice heard—Say “yes” when you see this pop-up so National Government Services can make your job easier!


Resources

• 935 Process

– www.cms.gov/MLNMattersArticles/downloads/MM6183.pdf

• Appeal

– Appeal timeframes

• www.cms.gov/OrgMedFFSAppeals/Downloads/AppealsprocessflowchartAB.pdf


Resources

• RAC Web site www.cms.gov/RAC

– Frequently asked questions

– Updates

– RAC statement of work

– Fact sheet

– Appeals information

– Change requests related to RAC

• RAC e-mail: [email protected]


Resources

• American Medical Association: www.ama-assn.org

– Contains CMS presentation, fact sheets

• American Health Information Management Association (AHIMA): www.ahima.org/infocenter/documents/RACToolkitFinal.pdf

– RAC toolkit available at no cost


Resources

• National Government Services Web site: www.NGSMedicare.com

• CERT Web site: www.CERTprovider.org

• CERT reports: www.cms.gov/cert

• Office of Inspector General reports: www.oig.hhs.gov/reports.asp


Medicare University

MU

• Educational Program designed to provide a broad variety of Medicare related training.

• View events on National Government Services Web site

• All teleconferences, Webinars, CBTs, and many seminars are FREE

• Registration is required.• Earn MUC Credits - Self Report after Training/

Print Report Card of all Training www.NGSMedicare.com,


Medicare University Training

Event Number: 10296SBLFT1

• Topic: The Recovery Audit Contractor (RAC) and Comprehensive Error Rate Testing (CERT)

• Medicare University Credits (MUCs): 1

• # of Sessions: 1

• Catalog Number: AA-C-00353


Thank You!

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