RAC ‘n Rehab© Series
CMS, without much fanfare, released a long anticipated Frequently Asked Questions
document regarding manual medical review of therapy claims over the $3700 thresholds. The FAQ is in reponse to the questions posed by the therapy stakeholder group a number of weeks ago prior their meeting with CMS on how the manual medical review would be implemented. Manual medical review of therapy claims over the $3700 thresholds ($3700 for PT and SLP combined and $3700 for OT) was mandated in the American Taxpayer Relief Act of 2012, and effective for claims beginning January 1, 2013. CMS had originally indicated that the Medicare Administrative Contractors would continue to conduct manual medical reviw, as they had done in the 4th quarter of 2012 when the program was phased in over 3 months. But CMS had also indicated they were looking for a permanent solution for a program that called for prepayment review of claims at the $3700 threshold, particularly since the legislation called for prepayment review within a 10 day timeframe.
CMS settled on a solution that involved entrusting the program to one of its review partners: the Recovery Auditors, formerly known as the Recovery Audit Contractors, and “affectionately” known as RACs. Effective 4-1-2013 the RACs took over the administration of the therapy manual medical review program with prepayment review to be conducted in those states that are already part of the RAC Prepayment Demonstration, and postpayment review to take place in all other states.
A few items of note for therapy providers:
- There will be no reimbursement for medical record costs, as in most RAC complex medical reviews
- The RACs will be paid on a contingency fee per the RAC program
- Medical records can be submitted via fax, mail, CD/DVD, or esMD
- RACs will use existing rules of manual medical review
- Current RAC ADR limits will NOT apply, meaning 100% review
- RAC discussion period is only available for postpayment review
The first RAC to post manual medical review of therapy claims was Connolly, the Region C RAC.