APMA News - September 2013 - (Page 34)

Reimbursement FAQs on Recovery Audit Contractors Recovery audit contractors (RACs) are CMS contractors responsible for identifying Medicare overpayments and underpayments. Medicare RACs accomplish this task primarily by identifying past improper Medicare payments to providers and by working with Medicare administrative contractors (MACs) to recoup identiﬁed overpayments. What should I do if I get a RAC request for medical records? You must respond in a timely manner or risk receiving an overpayment demand. You must send the records within 45 calendar days or request an extension by contacting the RAC within those 45 days. The RAC may decide that an overpayment exists if there is no timely response to a request for medical records. The RAC must clearly identify the deadlines in its request letter and must also identify the types of documentation that will assist the RAC in adjudicating the claim. When compiling records, you should be careful to include all necessary documentation. Submitting incomplete or illegible medical records can result in denial of payment for services billed. For Medicare to pay a claim, there must be sufﬁcient documentation in the provider’s records to verify that the services were provided to eligible beneﬁciaries; met Medicare coverage and billing requirements, including being reasonable and necessary; and were provided at an appropriate level of care and correctly coded. A comprehensive response to a RAC request can save time by preventing unnecessary appeals. Are there limits on the number of records a RAC can request? Yes. The limits are based on the number of physicians/ non-physician practitioners reported under each tax identiﬁcation number/ZIP combination in the previous calendar year. Group/Ofﬁce Size Maximum number of requests per 45 days Less than 5 10 records per 45 days 6–24 25 records per 45 days 25–49 50 records per 45 days What if I get a notice from the RAC that says “Informational” at the top? If the bolded header reads “Informational Letter” and the subject of the letter mentions “semi-automated review results are attached,” then the review is semi-automated. You will have 45 days to submit information to support your claim. If you do not respond within the given timeframe, the claim will be sent to your Medicare Appeals Contractor for adjustment and a demand letter will be issued. How soon after I provide records will I hear from the RAC? RACs must complete their reviews within 60 days from the receipt of the medical record documentation (they may request a waiver from CMS in extenuating circumstances), and their notiﬁcation to the provider must include speciﬁc information. How far can RACs look back at my claims? RACs have been using a three-year look-back period— that is, they do not audit claims older than three years. However, in 2012, Congress passed legislation that provided RACs the opportunity to audit claims up to ﬁve years old. To date, CMS has not used this additional authority to audit claims older than three years. 40 records per 45 days 50 or more If you receive a request that does not adhere to these guidelines, you should contact the RAC with documentation of the group size. If the number of full-time-equivalent physicians and non-physician practitioners is signiﬁcantly different from the number of individual rendering physicians and non-physician practitioners appearing in the RAC’s claim data, you may petition the RAC for a modiﬁed limit. For DME providers, the limit is 10 percent of all claims submitted for the previous full calendar year, divided into eight periods (45 days) with a cap of 250 records per 45 days. Note that CMS has reserved the right to increase the documentation limits under certain circumstances. 34 APMA News September 2013 Where can I get more information on RAC audits? Visit APMA’s new RAC Audit resource page at www. apma.org/RAC for more information on replying to a demand letter, appeals, and Medicaid RACs. ■ Contact the APMA Health Systems Committee at healthsystems.hpp@apma.org. http://www.apma.org/RAC http://www.apma.org/RAC

Table of Contents for the Digital Edition of APMA News - September 2013

APMA News - September 2013
President’s Message
Contents
What Happens in Vegas: The 2013 Annual Scientific Meeting
Annual Scientific Meeting Sponsors
Humanitarian Surgical Missions: A Different Kind of Residency Training
Collaboration is Key at Limb Salvage Clinic
Center for Professional Advocacy Reviews Recent California Medicaid Lawsuit
Oregon Podiatrists Achieve Physician Status
Letters to the Editor: Solving Our Residency Crisis; Remembering Our Heroes
Resolutions Submission Deadlines
Reimbursement
ICD-10: How to Code for Painful Hammer Toes
Federal Advocacy Forum
Cosponsors to the Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians Act
APMAPAC Chair Report
Coverage Corner
Bylaws Propositions Due
IT Consultant
Website Wisdom
On the Road with APMA
Small Business 101
CPME Update
In Short
Worthy of Note
Affiliates Corner
New Members
Death Notices
APMAPAC Update
Development Update
Classified Advertising
Dates to Remember
Advertising Index
10 Questions
Your APMA

APMA News - September 2013