In several recent communications from the AHA and the RACs themselves during provider outreach sessions, providers are being offered clarification on exactly how RAC review determinations are going to be conveyed. In a member advisory issued April 20, the AHA offered the following under "Medicare Recovery Audit Contractors (RACs): Permanent Program Basics" on how the review results letters and demand letters will notify providers of the determination and collection process.

"The determination process for the RAC has not changed," according to Connie Leonard, director of the Division of Recovery Audit Contracting for CMS/OFM. "There has been a lot of confusion surrounding the discussion period and we are attempting to provide clarification to providers." The term "review results" often are used now in place of "determination," as "review results" just are simpler to understand. It is still a determination of the review (an underpayment, overpayment or no finding).

For an automated claim review:

The provider will be issued only a demand letter; there is no review results letter. The discussion period is from Day 1 (from the date of the demand letter) through Day 41.

A RAC is required to communicate to a provider the results of each automated review that invokes an overpayment determination, including the coverage/coding/payment policy/article that was violated. In the case of an automated review that results in an overpayment, the provider will receive a demand letter that communicates the finding of one. This letter may contain a list of claims denied for the same reason. The provider will not know that the RAC is looking at a particular claim until the time that a demand letter is sent, as no medical record was requested. However, a provider will know that the issue was approved for wide-scale automated review by CMS because it will be posted on the RAC's Web site.

The demand letter will come directly from the RAC and will contain the following information:

• The amount of the denial
• The method for calculating the denial
• The reason the original payment was incorrect
• The regulatory and statutory basis for the denial
• The providers' option to submit a rebuttal statement (described in the AHA Medicare appeals advisory, available at http://www.aha.org/aha/advisory/2009/090327-regulatory-adv.pdf
• The providers' appeal rights, which are separate from the rebuttal process
• The recoupment, payment and interest options for the provider and the associated timelines.