{"id":70,"date":"2018-03-22T15:52:05","date_gmt":"2018-03-22T15:52:05","guid":{"rendered":"https:\/\/advantagehcconsulting.com\/blog\/?p=70"},"modified":"2018-03-22T16:13:27","modified_gmt":"2018-03-22T16:13:27","slug":"medical-review-dont-be-surprised-if-rac-review-is-around-the-corner","status":"publish","type":"post","link":"https:\/\/advantagehcconsulting.com\/blog\/2018\/03\/22\/medical-review-dont-be-surprised-if-rac-review-is-around-the-corner\/","title":{"rendered":"Medical Review: Don’t Be Surprised If RAC Review Is Around The Corner"},"content":{"rendered":"

\"\"<\/h3>\n

Monthly billing make hospice claims a tempting RAC target.<\/strong><\/em><\/span><\/h3>\n

Recovery Audit Contractor\u00a0Performant<\/span>\u00a0<\/strong>has yet to name a specific audit topic related to hospice, but that doesn\u2019t mean you shouldn\u2019t worry about RAC review.<\/p>\n

Why?<\/span>\u00a0<\/strong>Experts predict the RAC that has Medicare\u2019s home health, hospice and DME contract will announce hospice audit topics, particularly given the increased worry about fraud and abuse voiced by the\u00a0HHS Office of Inspector General<\/strong><\/span>\u00a0and other government agencies. The fact that Performant recently named its first home health audit topic, on \u201cDocumentation and Medical Necessity,\u201d could indicate a hospice topic isn\u2019t far behind.<\/p>\n

In the past, RACs haven\u2019t given attention to hospices because the amounts recovered per claim paled in comparison to providers like hospitals, and the RACs were paid on contingency. That\u2019s likely why the\u00a0Centers for Medicare & Medicaid Services<\/span>\u00a0<\/strong>eventually decided to award one national RAC contract for home health, hospice and durable medical equipment.<\/p>\n

RAC audits aren\u2019t just a problem for providers with high denial rates, notes consultant\u00a0Cindy Krafft\u00a0<\/strong>with\u00a0Kornetti &amp; Krafft Healthcare Solutions<\/strong>. Gathering all requested materials and submitting them within the RAC\u2019s 45-day timeline will translate into serious \u201cresource consumption,\u201d Krafft says.<\/p>\n

When you add denial recoveries on top of the cost of responding to ADRs appropriately, \u201cfinancial implications could be high,\u201d Krafft warns.<\/p>\n

Extrapolation Could Be Waiting In The Wings<\/strong><\/span><\/h3>\n

Watch out:\u00a0<\/strong><\/span>An even deadlier reimbursement blow may be in the offing as well. Performant assures providers in a Frequently Asked Question set on its website that \u201ccurrently Performant is not using extrapolation.\u201d However, the RAC adds that \u201cwe have been approved to perform this method of analytics.\u201d Performant does promise it will furnish \u201cappropriate communication\u201d on its website \u201cwhen we plan to perform this process.\u201d<\/p>\n

But in its Region 5 Statement of Work, CMS goes into more detail that indicates it may consider extrapolation a good fit for home care claims, at least eventually. \u201cThe Recovery Auditor is encouraged to use extrapolation for some claim types when all requirements are met,\u201d the SOW reads. \u201cExtrapolation may be cost effective for low-dollar claims that require complex review and have a history of having a high error rate.\u201d<\/p>\n

However, Performant will have to secure CMS approval for extrapolation on an issue-by-issue basis, the SOW indicates.<\/p>\n

Along with RAC reviews, expect to see appeals of RAC determinations pile up, offers finance expert\u00a0Tom Boyd\u00a0<\/strong>with\u00a0Simione Healthcare Consultants\u00a0<\/strong>in Rohnert Park, California.<\/p>\n

However, CMS does note in its Statement of Work that is expects a 95 percent \u201caccuracy rate\u201d in RAC reviews, and that it expects fewer than 10 percent of determinations to be overturned at appeal.<\/p>\n

Reminder:<\/span>\u00a0<\/strong>RACs are paid solely on a contingency fee basis, earning a percentage of the recoveries they produce from their reviews. They do get paid for underpayments they find as well as overpayments, however, notes\u00a0National Association for Home Care & Hospice\u00a0<\/strong>President\u00a0William Dombi<\/strong>.<\/p>\n

For Performant\u2019s work as the home health, hospice, and DME RAC, it receives an 8 percent contingency fee, a CMS spokesperson says. That rate was disclosed when CMS announced the contract for Region 5, which covers the entire nation, in 2016.<\/p>\n

But Performant can earn an even higher fee than 8 percent, the CMS source notes.<\/p>\n

How?<\/span>\u00a0<\/strong>The Statement of Work for Region 5 specifies that for every point a RAC comes in under the 10 percent appeal overturn cap, it will earn a 0.1 percent increase to its contingency fee. Thus, Performant can earn an 8.1 percent fee if its overturn rate is 9 percent, an 8.2 percent fee if its overturn rate is 8 percent, and so on. Theoretically, if the RAC had a 0 percent overturn rate, it would receive a 9 percent fee. Of course, a 0 percent rate is pretty much impossible.<\/p>\n

Presumably to counteract the bounty hunter incentives to the contingency fee contract, CMS does impose some adverse actions if Performant exceeds the 10 percent overturn rate. Those consequences range from reducing the number of Additional Development Requests the RAC may issue to terminating its contract.<\/p>\n

Why Hospice Claims May Soon Be In The RAC Crosshairs<\/strong><\/span><\/h3>\n

The contingency fee payment structure incentivizes the RAC to seek out the highest-dollar claims with problems for review, notes consultant\u00a0Pam Warmack\u00a0<\/strong>with\u00a0Clinic Connections\u00a0<\/strong>in Ruston, Louisiana. Denials of those high-payment-level claims will result in the highest payments to Performant.<\/p>\n

The contingency fee structure makes hospice claims a tempting target, Boyd suggests. That\u2019s due to the dollar amount of the average hospice claim versus home health agency claim, Boyd says.<\/p>\n

The good news is that the 10 percent cap on successful appeals should help temper Performant\u2019s zeal for denying claims. \u201cLimits on incorrect decisions [are] a good thing for agencies,\u201d says\u00a0Judy Adams\u00a0<\/strong>with\u00a0Adams Home Care Consulting\u00a0<\/strong>in Durham, North Carolina. \u201cIt should mean a decrease in nit-picking denials.\u201d<\/p>\n

Warmack agrees, saying \u201cit is encouraging to know that they are held to a performance indicator.\u201d<\/p>\n

Appeal RAC Denials<\/strong><\/span><\/h3>\n

If you receive a denial from the Recovery Audit Contractor when it reviews your claim, all is not lost.<\/p>\n

\u201cAppeal every denial,\u201d Boyd emphasizes.<\/p>\n

First step:<\/span>\u00a0<\/strong>Before you file a formal appeal, you can request a \u201cdiscussion period\u201d from the RAC.<\/p>\n

\u201cYou are encouraged to file a Discussion prior to an Appeal,\u201d Performant said in a webinar for providers given last year. \u201cThis gives the RAC the opportunity to evaluate the original determination.\u201d<\/p>\n

Using the Discussion option \u201clessens the administrative burden for both you and your Medicare Administrative Contractor,\u201d Performant said.<\/p>\n

Providers have 30 calendar days from the RAC determination to submit a request for a Discussion Period, the\u00a0National Association for Home Care & Hospice\u00a0<\/strong>says in its provider newsletter. The 30-day period begins from the date of the Review Results letter. The RAC has 30 days from receipt of the Discussion Period request to respond to the provider.<\/p>\n

If you do decide to move forward with a formal appeal, it goes through the usual process via your Medicare Administrative Contractor, Performant noted.<\/p>\n

Note: See the Region 5 SOW at\u00a0www.cms.gov\/Research-Statistics-Data-and-Systems\/Monitoring-Programs\/Medicare-FFS-Compliance-Programs\/Recovery-Audit-Program\/Downloads\/New_RAC-SOW-Region-5-clean.pdf<\/a>.<\/em><\/p>\n

If you have any question book a call here for a free consultation:<\/span> Advantage Healthcare Consulting<\/a><\/span><\/em><\/p>\n

Source- SuperCoder<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Monthly billing make hospice claims a tempting RAC target. Recovery Audit Contractor\u00a0Performant\u00a0has yet to name a specific audit topic related to hospice, but that doesn\u2019t mean you shouldn\u2019t worry about … Continue Reading →<\/a><\/p>\n","protected":false},"author":1,"featured_media":71,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8,6],"tags":[11,12,13],"class_list":["post-70","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-compliance","category-medical-review","tag-home-care","tag-hospice","tag-ltc"],"_links":{"self":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/70","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/comments?post=70"}],"version-history":[{"count":3,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/70\/revisions"}],"predecessor-version":[{"id":98,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/70\/revisions\/98"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media\/71"}],"wp:attachment":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media?parent=70"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/categories?post=70"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/tags?post=70"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}