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RAC Work Pause and Therapy Manual Medical Review

February 24, 2014 1 Comment

The CMS RAC Work pause of the Recovery Auditor (RAC) program closedwill provide some work load relief for outpatient therapy providers in the short run, but in the long run 100% of therapy claims over the $3700 thresholds will be reviewed.  So what does this mean for therapy providers?  Check your mail, if you are in a prepayment review state, the last date the RAC can send a letter requesting prepayment review of claims over the $3700 threshold is this Friday, February 28th.  Last Friday (2/21/2014) was the last date that ADR letters could be sent for post-payment review.  Be on the lookout for a flood a ADR requests for the RACs to catch up with any delays in sending the post payment review requests.

RAC Work Pause and MMR – Provider Tips

All therapy ADR requests that you receive dated appropriately for either 2/21 or 2/28 must be fulfilled.  Here are some tips to get you through this process and not receive any unnecessary denials.  (If this information is updated by CMS, we will update this post).

  1. You must comply with the any ADR request and submit the records, or a denial will be made on those claims where you have failed to respond to the ADR.
  2. You must also comply with any ADR requests that were in the pipeline prior to the last Friday’s announcement.
  3. All therapy over the $3700 thresholds will be paid during the RAC pause period, but will be subject to review per the ATRA legislation.
  4. Post payment reviews for all therapy over the $3700 thresholds will take place when the new RAC contracts are awarded and work resumes.
  5. Best practice – identify all therapy claims that will be reviewed and assemble documentation as if you had the ADR request in hand.
  6. Summary – 100% of all therapy over $3700 will be reviewed – you just have a break right now.

Therapy Manual Medical Review  – Brief Background

The Recovery Auditors have been reviewing therapy claims over the $3700 thresholds since 4/1/2013.  In the 11 prepayment review states, the MACs send therapy providers an ADR letter instructing them to send the requested information to the RAC.  The RAC has 10 business days to review the records and render an opinion, if the records cannot be reviewed within the 10 days, the provider is to be paid.  In the other 39 states the RAC sends the ADR letter and request records.  The post-payment review is not limited to the 10 day review (remember, you have already been paid for the claim), however providers are reporting that they are receiving batches of post-payment review letters nearly 10 months after the claim has been submitted.  Therapy RAC reviews for manual medical review are not subject to the established RAC ADR limits.

Do you have questions about the program?  Let me know if you have received ADR requests for prepayment review and post-payment review last week and in the coming week.  How far back are the dates of service?  How many ADR requests did you get?

Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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  1. Mitch Kaye says:

    Nancy,

    I have heard you say several times that in the prepayment states if the records cannot be reviewed in 10 days, the provider is to be paid. Can you give me the link to that specific requirement?

    I remember when threshold reviews initially started that this was to be done but the provider had to receive a latter from the MAC stating that the review could not be completed within 10 days and the claim would be paid. The only statement I have been able to find since the pre/post payment reviews started is that the RAC audits should be completed within 10 days but I have not seen anything to indicate that if the review is not done within 10 days payment would be automatic. What does a practice have to do to receive their payments in these situations?

    Thank you.

    Mitch Kaye, PT

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