Rac ‘n Rehab Series© Therapy prepayment review by RACs takes place in the 11 states where the RAC prepayment review is in place, the RACs have 10 days from the receipt of your records to review the records and render an opinion. If the review is not completed in the 10 day time frame, the claim must be automatically paid, regardless of the review findings. CMS experimented with manual medical review of therapy claims at the $3700 threshold for the 4th quarter of 2012. Based in part upon “success” with this program and recommendations of the Medicare Payment Advisory Commission (MedPAC) Congress included it in the ATRA legislation for 2013. The SGR legislation extended the therapy caps exceptions process as well as manual medical review of therapy claims at the $3700 threshold through March 31. 2014. Since April 1, 2013 manual medical review has been conducted by the Recovery Auditors (RACs).
Zoom In and Check the Dates
If you have received a denial letter based upon submission in response to a manual medical review request, the first thing you should do is to check your verification receipts for the ADR’s arrival at the RAC. That would include the fax date receipt, an expedited delivery service receipt, or a good old green card receipt from the US Postal Service. The best receipt in these situations would be your electronic submission of medical documentation (esMD), a CMS approved program with approved vendors. If the date of your denial letter falls outside the 10 business day review, and you are in a prepayment review state, your are entitled to payment under ATRA. Where it gets sticky is when you calculate 11 or 12 days and the RAC calculates 10 days, however, the majority of cases that have been paid have fallen way outside the 10 days review. Providers have reported that the records were reviewed, and findings were noted, but were paid because of the 10 day limitation. Provider have also noted that review letter just simply stated a finding of “pay” due to 10 day review limitation.
Charts Still Subject to Review
Records may still be subject to review under other CMS review programs, even though their was a payment due to the 10 day limitation. Many providers have breathed a sigh of relief when receiving payment, but don’t let a false sense of security set in, as providers are reporting challenging comments by the RACs in denying claims. While the appeals process is open and ready for your RAC denials, appeals cost time, effort and cash flow. Best practice is to ensure that any episode of care that that is outside the bell curve on the high side should ensure documentation that supports the reason for more therapy, starting with the reason that the therapy cap is being exceeded (KX modifier).
Good luck in this process. I would like to hear from you on your challenges with therapy prepayment review by the RACs. The therapy industry does not have the unification of the hospital industry in addressing the issues with the recovery audit (RAC) program. And there is no active outpatient therapy objective data collection on the RAC experience, only anecdotal stories. Let me know your thoughts!