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Important notice to Medical providers/ Hospitals: starting in 2010, CMS (Medicare) has hired four RAC (Recovery Audit Contractors) to pursue claim billing violations. Their mission is to collect as many $$$ in overpayments as possible nationwide. They\\’re heavily incentivize (17% of what they collect). This presentation provides an overview of the RAC program as well as our baseline audit service to help protect you against the impending RACs
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Recovery Audit Contractors (RACs) Medicare, Medicaid and Commercial Insurance
What you Need to Know
Med-Billing Solutions, LLC
Introduction
Med-Billing Solutions, LLC
Stephen St. Gelais, Owner/ Consultant
• Part of a nationwide network of over 1500 independently operated offices; established in 1994
• We specialize in assisting medical providers nationwide with enhancing their cash-flow, profitability and office productivity.
• We accomplish this through a variety of our proprietary state-of-the-art billing solutions services.
Our Core Service Focus
• #1 Responsibility: Insure we're capturing the workload documentation you have performed with your patients
• #1 Goal: Assure that you're receiving the maximum revenue you're entitled by optimizing your "RVU" (Relative Value Unit).
• #1 Priority: "Denial Management“
Medical Billing & Coding
Stephen St. Gelais
Financial Services
Edward Albrecht
Certified Public Acct.
Kristine Vail
Marketing & Advertising
Bob Charney
Banking & Finance
Alice Madrid-Neumann
Information Technology
Terry Schladetzky
Business Brokerage
Robert Fiance
Real Estate
Linda Brown
Joining us soon –
Legal, Medical Waste, Construction and more…
Flagship Charity:
"OwieBowWowie and Friends Foundation”
Gina Gippner-Woods
Introduction
Dedicated to serving the medical community
Med-Billing Solutions, LLCProviders Coding Resource
Agenda
• What is the RAC?
• How does the RAC affect providers?
• What does the RAC do?
• Who oversees the RAC?
• Major RAC findings/ Compliance
• RAC process (what to expect)
• How do Providers Prepare?
What is the RAC?
• Recovery Audit Contractor (RAC)• Independent contractors, hired by CMS, authorized by
Congress• 3 state pilot program in place since 2003 (hospitals only)–
over $1B of overpayments collected• RAC objectives:
• Documentation and coding inconsistencies• Overpayments (& Underpayments) made to the
providers based on the findings• Clear documentation to support the medical
necessity of the services being provided or dispensed
RAC Mission
• “Ensure integrity of Medicare Fee For Service claims through the identification and correction of improper payments. Protect Medicare Trust Fund, prevent fraud, abuse and waste” – CMS
• Tax Relief and Healthcare Act of 2006, Section 302 requires a permanent & nationwide RAC by 1/1/2010 to protect Medicare trust funds.
Recovery Audit Contract-”RAC”
4 (Four) Private firms to perform medical records and billing audits on providers in all 50 states and Puerto Rico
Provider types targeted• Inpatient Rehabilitation
Facilities
• Hospitals
• Physicians (especially high ticket services)
• Skilled nursing facilities
• Durable medical equipment suppliers
• Laboratories, Ambulance, Other
• Home Health Agencies
• Hospices
Regions and timelines
D
C
B
A
March 1, 2009 March 1, 2009 March 1, 2009
March 1, 2009 March 1, 2009 March 1, 2009
August 1, 2009 August 1, 2009 August 1, 2009
Provider Outreach Claims Available for Analysis Earliest Correspondence
*RACs are required to perform outreach programs for all providers in their region
From CMS
HealthDataInsights – RAC Auditor
https://racinfo.healthdatainsights.com/home.aspx
RAC contingency fee %
RACs are paid on a contingency fee payment basis Based on the amount of the improper payments they collect Both overpayments and underpayments. RAC compensation 10-13% (on what they collect)
Source: CMS http://www.cms.hhs.gov/RAC
How the RAC affects the Provider
If the providers bill Fee-for-Service Medicare, Medicaid or Commercial Insurance programs, their claims will be subject to review by the investigators and auditors
Not at risk: practices/ facilities with high % (70%+) Medicare HMO Advantage, Medicare prescription
What about the other entities
• Medicaid/Medi-Cal (partially funded by the federal government and
managed by each state)– They are hiring firms like Healthnet Federal Services to mimic the
identical issues as the federal government
• RAC’s will work/ coordinate with Medicare and Medicaid fraud teams:– PSC: Program Safeguard Contractor– ZPIC: Zone Program Integrity Contractor
Private Insurance
• Aetna and other insurance carriers are pursuing the RAC process as well
WHY?
Because they have implied authority to review all providers claims
What does the RAC do?
• Review claims and medical records on a post payment basis
• Review claims paid after October 1, 2007
• RACs will be able to review medical records three years from the date the claim were paid
• Collect overpaid claims paid
Who Oversees the RAC?
The RVC ( RAC Validation Contractor)
Independent third party review entity to work with CMS to provide additional oversight
Ensure the RACs are making accurate claim determinations in the permanent program.
CMS announced it hired Provider Resources, Inc. of Erie, PA as the RVC
Source: CMS http://www.cms.hhs.gov/RAC
Evaluation and Management (E/M)
Major RAC Findings1)Medicare’s global surgery payment rules even in
cases involving E/M services.2)E/M services that are not reasonable &
necessary.3)Duplicate E&M codes (results in overpayment)4)New vs. established (patient) E&M codes5)Units of service (injections)
Importance of Documentation Compliance
• The medical record or chart notes must match the codes you submit
• Evaluation & Management (office visit)• Diagnosis• Injections• Supplies
• Medical Necessity must clearly state the need for all services provided or prescribed.
Claims Audit Process PhasesI. Data Screening & Claim Selection
II. Medical Record Request
III. Record Review and Status Determination
IV. Post Review Notification
V. Overpayment Recoupment
VI. Post Determination
RAC Claims Audit Process Overview
Automated review
Example 1: Use information systems to find two or more identical surgical procedures for the same beneficiary on the same day at the same hospital. (Medicare claims editor systems can identify these prior to billing.)
Detects clearly improper Payments (overpayment or underpayment determination) without evaluating the medical record associated with the claim.
Source: CMS http://www.cms.hhs.gov/RAC
When the RAC arrives
• Physician provides a clear response to the letter within 45 days
• Retain a certified coder - review the records prior to submission
• Send copies of the charts to the RAC- signature required notification of receipt.
• Digitized/electronic file of your charts and supporting documentation.
WATCH THE MAIL FOR A RESPONSE
Fiscal Year 09Medical Record Limits
Physicians• Single Practitioner: 10 medical records per 45 days per NPI• Partnerships 2-5 individuals: 20 medical records per 45 days
per NPI• Groups 6-15 individuals: 30 medical records per 45 days per
NPI• Large Group Practices 16+ individuals: 50 medical records per
45 days per NPI
Other Part B Billers (DME, Labs) • 1% of the average monthly Medicare claims (max 200) per NPI
per 45 days
Collection Process
•RAC will issue a Demand letter
•RAC will offer an opportunity for the provider to appeal the decision
•Recoups by offset unless provider has submitted a check or a valid appeal
Providers HAVE NO CHOICE…
THEY TAKE THE $$ DIRECTLY FROM YOUR MEDICARE CHECK
Key Timeframes (15, 30, 40, 120)
• 15 Days: Rebuttal process (Recoupment challenge)
• 30 Days: Repayment Plans (Interest @12% starts on day 31)
• 40 Days:Recoupment process begins on 41st day
• 120 Days:Appeals must be filed
What to Expect Next
The RAC will repeat the exact same process every 45 days until they find no more
overpayments
How to Prepare Your Practice
• Perform an independent baseline audit assessment to identify areas of non-compliance with Medicare/Medicaid rules
• Identify any corrective actions required for compliance
• Implement any required changes to stay in compliance
• Establish “Go-To-Team” – RAC Consultant & Certified Coders
MBS SupportBase-Line Audit Process
Medicare Documentation &
Coding Benchmark Audit
•Random selection of 50 office notes
Fax to HIPAA secure site
(iDocumentsNow)
for certified coders to
review
Documentation and coding Compliance audit performed
by certified coders
Web-based Training
AuditReport
MBS – Your “go-to” team•RAC Audit Management•RAC Findings Review•RAC Appeal
•All Medical Specialties•Designed for Physician
•Training for your coding team/ staff
Beyond the Base-Line Review
• Billing team must track all denied claims
• Identify all the issues• Look for patterns• Deploy any corrective actions to
avoid improper payments
Review
• The RAC is to be taken seriously• The RAC can have a severe negative impact to an unprepared
Practice – both financially and disruptive• Once started, The RAC repeats the process every 45 days – they
won’t stop until they’re convinced there are no more violations• Medicare is NOT likely to be the only payer going to take a peek (
private insurance, Medicaid/ Medical)• Know where you stand - Have a Base-Line Audit done
When the RAC arrives…..
Let MBS be your “Go-To Team”
Services
Med-Billing Solutions, LLC
Services: • EMR i-Billing : Full Service, State-of-the-Art• EMR i-Solutions : One-stop solution• RAC Base-Line Audit Services• RVU-MAX - Coding Services (24-Hour)• MaxCollect™ Profit Recovery• Cash Flow Solutions
Complimentary Complimentary Practice AnalysisPractice Analysis
Thank You
Med-Billing Solutions, LLC
Stephen St. Gelais
MBS Consultant
805-428-4566
www.med-billingsolutions.com
Med-Billing Solutions, LLCProviders Coding Resource
Medical Billing & Coding
Stephen St. Gelais
Financial Services
Edward Albrecht
Certified Public Acct.
Kristine Vail
Marketing & Advertising
Bob Charney
Banking & Finance
Alice Madrid-Neumann
Information Technology
Terry Schladetzky
Business Brokerage
Robert Fiance
Real Estate
Linda Brown
Joining us soon –
Legal, Medical Waste, Construction and more…
Flagship Charity:
"OwieBowWowie and Friends Foundation”
Gina Gippner-Woods
Introduction
Dedicated to serving the medical community