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Don’t Get Caught in the RAC Trap:  Effective April 1, 2013 Manual Medical Review  = Recovery Auditors (RACs).   

RAC, Nancy BeckleySince April 1, 2013 the Recovery Auditors (RACs) assumed responsibility for Manual Medical Review of therapy claims over the $3700 threshold ($3700 for PT and SLP combined, and $3700 for OT).  Providers that are in the states where the RAC Pre-payment Review Project is underway will have their claims held for prepayment review.  The MAC will provide providers a prepayment ADR request, directing that documents be sent to the regional recovery auditor (RAC) for prepayment review.  Provider in the remaining 39 states will have their claims paid by their Medicare Administrative Contractor (MAC), but a ADR will be generated for post payment review, directing that documents be sent to the RAC for review.

What does this mean in terms of cash flow?

Prepayment Review States: Providers residing in Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri, will experience a lag in payment time consistent with the prepayment review process, which is expected to be 10 days review time, in addition to MAC correspondance to the provider, provider submitting records to the RAC, and the RAC communicating the results of the review to the MAC, who is responsible notifying the provider.  The normal CMS appeals process and rights apply in the RAC  program.

Post-payment Review States:In the 39 remaining states, the RACs will conduct immediate postpayment review. The MAC will flag the claims that over the $3700 threshold and request additional documentation be sent to the RAC, but also pay the claim.  The Recovery Auditor will conduct postpayment review and will notify the MAC of the payment decision.  Again, the normal CMS appeals process and rights apply in the RAC  program.

The RAC Prepayment Review Demonstration began in August 2012 with specific targeted hospital DRGs to be phased in for review in states where there is demonstrated potential for high fraud and abuse.   CMS has not provided additional clarification to the provider community if the current Recovery Auditor Statement of Work (SOW) includes directives for additional review issues in the demonstration program.  Stay tuned.

Other RAC News:  Read the blog post on Connolly, the Region C RAC posting of 4 issues on manual medical review of therapy claims.

2010: RAC Demand Letters in the Mail

In 2010 Rehab providers were in receipt of Demand Letters in Region A (Region C addressed this in 2009) and other regions for the billing of untimed codes in units greater than 1 (one).  The Recovery Audit Contractors for Region C (Connolly Healthcare) Region D (HealthDataInsights) and Region B (CGI) have all posted the CMS approved issue of Region A (DCS) untimed Codes for automated review.  Further tips on managing the issue of untimed codes should help you gain further insight into the issue of untimed codes and what you can do to prepare yourself.

When you select Nancy Beckley & Associates LLC for your rehab project, you are working with credentialed professionals with extensive experience in rehabilitation.   We have provided a sampling below of the various types of projects in which we are involved.  Call (414) 748-4376 to discuss your potential project.

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