4/19/2013
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CMS RAC Statement of Work 2013
An Overview of Important Changes, as of April 2013
4/19/2013
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Page § 5
What’s Our Source?
Posted by RAC Monitor on 4-18-2013
Unpublished PDFs
Two PDFs and a map image
Part of a GSA Request for Quote
Offered to GSA Contractors only
Bid deadline was April 4?
Announce Awards: Unknown
4/19/2013
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WHY Do We Now Have FIVE RACs?
CMS separated FFS Recovery Audit functions
into those submitted to an A/B MAC versus
those submitted to DME MAC and Home
Health/Hospice MAC.
So... a new, fifth RAC, devoted to DME/HHH.
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4/19/2013
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RAC Statement of Work 2013 General Tasks Included
RACs must:
Perform Post payment review of all Medicare claim and provider types
(excluding DME/HHH) AND a review of claims/providers that show a "high
propensity for error" as shown in CERT and other CMS analysis measures.
Perform Prepay review, per the Prepayment Review Demonstration -- active
only when CMS has authority to use the RACs for this.
Support CMS at all level of appeals, including "taking party status" at the ALJ
level in at least 25% of cases reaching that level.
Share methods, algorithms and edits used to find errors, with CMS and the
MACs.
Perform "necessary provider outreach to notify provider[s]" of purpose, etc.
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4/19/2013
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RAC Statement of Work 2013 Transitions
What happens if there is a "new" RAC?
What about all that work you just did?
What if you issued denials...
...and appeals are still pending...
...when the new RAC takes over?
You still collect your fee for that work, right?
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4/19/2013
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RAC Statement of Work 2013 Transitions
WRONG ANSWER!What happens if there is a "new" RAC?
ANY REMAINING RECEIVABLES FOR A RAC
- DENIALS BEING APPEALED AT ANY REMAINING LEVEL -
WILL 'TRANSITION' TO THE NEW CONTRACTOR.
Therefore, existing RACs lose those fees.
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4/19/2013
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RAC Statement of Work 2013 Transitions
How long does it take to transition to a "new" RAC?
Transition plans must be presented.
Work stoppage could happen.
Stoppage could last 3 to 6 months.
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4/19/2013
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RAC Statement of Work 2013 New RAC Tasks
RACs are now asked to --
"identify and report LCDs"
... ones that may benefit from CMS evaluation
... because of being outdated, flawed, etc.
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4/19/2013
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RAC Statement of Work 2013 New RAC Tasks
RACs are now asked to --
"submit monthly appeals reports"
... this is a new requirement.
... how many times the MACs request records?
... how many times the MACs affirm appeals?
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4/19/2013
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RAC Statement of Work 2013 Geographic Regions
The previous SOW included an exception for claims
processed by Wisconsin Physician Services (WPS)
-- that exception is now gone?
-- presumably because the map has been redrawn?
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4/19/2013
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RAC Statement of Work 2013 Transitions
The Validation Process was moved and there are
three changes to note:
• must post a new issue to their website, but no longer
mentions having a separate page for such postings.
• must post "review type", added to all the other items.
• must allow sort by posting date, plus provider type.
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4/19/2013
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RAC Statement of Work 2013 Review Type Percentages
CMS "may now impose percentage requirements
[for RACs to review] by claim types"
-- not to LIMIT the amount of reviews
-- but to ADD claim types specified by CMS.
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4/19/2013
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RAC Statement of Work 2013 Preventing Overlap
CMS added ZPICs, PSCs, OIG, FBI, DOJ
• Now able to input claims into the master table
of exclusions
• To avoid claims being reviewed by multiple
agencies simultaneously.
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4/19/2013
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RAC Statement of Work 2013 Payment for Copies of Medical Records
The old SOW stated:
CMS might assign a maximum payment amount per
medical record to be paid for copying & postage for
delivery of medical records for ADRs.
Now, the Max is: $25.00 total per medical record.
(about 200 pages plus postage)
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4/19/2013
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RAC Statement of Work 2013 Time To Review Claims
Time Frame to conduct a Complex Review: 30 days
• Previously 60 days
• RAC loses their fee if they take longer without
permission from CMS.
• No limit on the extension(s)...
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4/19/2013
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RAC Statement of Work 2013 Communications
As before, must communicate results of:
• Complex Reviews - ALL
• Semi-automated -- ALL
• Automated -- Denials only
• No timeframes designated
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4/19/2013
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RAC Statement of Work 2013 Discussion Period
No changes to the Discussion Period.
Must request in writing
Within 30 days of MAC Demand Letter “and/or” Review
Results Letter from a RAC
NOTE: if a physician (employed by provider) requests to
speak to the CMD, then the request must be acted upon.
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4/19/2013
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RAC Statement of Work 2013 Determine Overpayment Amounts
CMS has added two new terms:
• Full Denial
• Partial Denial
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4/19/2013
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RAC Statement of Work 2013 Determine Overpayment Amounts
Full denials
• includes language that IP care was not necessary at
any time during the stay... does this mean that if a
time is visible where IP is not appropriate, then IP is
not available -- OR do they mean that IP was not
appropriate at any single point in time?
• what does "at any time during the admission"
mean?
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4/19/2013
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RAC Statement of Work 2013 Determine Overpayment Amounts
Partial denials
• the RAC decides what was reasonable and necessary (no
mention of the medical record) OR determine the correct code
for the service "described in the medical record."
• How do they determine the amount?
• THEY DON’T -- the MAC does...
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4/19/2013
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RAC Statement of Work 2013 Determine Overpayment Amounts
Partial denials
• the RAC notifies the MAC
• the MAC then adjusts the claim
• "preferably via the file-based mass adjustment process"
• At that point, only the difference is collected.
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4/19/2013
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RAC Statement of Work 2013 ID of Improper Payments on Prepayment Review
Page § 5
Prepayment Reviews
• Prepay reviews not included in previous SOW
• Reviews of either-or-both claims and providers
• RACs do NOT choose claims to review
• CMS chooses, MAC/FI/Carrier flag for prepay
• RACs review all those claims
4/19/2013
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RAC Statement of Work 2013 ID of Improper Payments on Prepayment Review
Page § 5
Prepayment Reviews
• medical records will be requested
• not clear if ADRs come from the MAC or the RAC
• There are NO limits to these ADRs.
4/19/2013
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RAC Statement of Work 2013 ID of Improper Payments on Prepayment Review
Page § 5
Prepayment Reviews
• RACs must complete their review and then
communicate results to the MAC within 30 days of
the day they receive documentation, so to comply
with payment regulations
(Claims Processing Manual Publication 100-04 Chapter 1, Section 80.3.3)
4/19/2013
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RAC Statement of Work 2013 ID of Improper Payments on Prepayment Review
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Prepayment Reviews
• MACs pay or deny based on RAC review results
• No extensions will be granted to the RAC
• There is no Discussion period for these reviews
• Associated claims MAY be reviewed, per CMS
4/19/2013
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RAC Statement of Work 2013 Learning from Trends
Page § 5
Expectation
"Auditors are expected to review data provided by
appeals contractors to identify ongoing trends or
issues of vulnerability that may be applied to current
reviews or potential appeals."
4/19/2013
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RAC Statement of Work 2013 Contact with Journalists
A paragraph specifically restricting
RACs from responding to any and
all reporters for information about
the RAC Program.
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4/19/2013
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RAC Statement of Work 2013 Approved Issues List Webpage
The paragraph about a Medicare Recovery
Auditor webpage does not now include any
mention of a separate page to list all the
approved issues.
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4/19/2013
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Gerrymandered Map
Appears to be done by number
of claims available for review.
WPS Exception is no longer
included.
More analysis forthcoming...
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RAC Statement of Work 2013 New State Map of Jurisdictions
4/19/2013
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1-800-680-6067
http://www.appealacademy.com
Do You Have
Any Questions??? ?Page § 24
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