The rollout schedule of the meetings has been updated several times since its initial posting, and it is prudent to check back frequently for additions, updates and contact information. Of interest: all the scheduled provider outreach sessions in Texas were cancelled, and more provider outreach specialty sessions are being scheduled and coordinated by associations such as the American Health Care Association, Home Care Association of New Jersey, New York Medical Equipment Providers Association, SAVA Senior Care and the HFMA.



The provider outreach updates have been somewhat comical at times.


The initial Florida meeting listing of “providers,” sponsored by the FHA, was closed to any facility that was not a member hospital. In an updated version of the schedule the meetings retroactively were listed for hospitals only. The scheduled Texas provider meetings in Dallas and San Antonio, including a Webinar, were cancelled “due to the health risks associated with H1N1 flu virus;” however, during the same time period Trailblazer, the Texas MAC, hosted a traveling show called (in true rock band style) “The 2009 J4 Medicare Tour” in Dallas and Houston. (I wonder if t-shirts were available?) So was it really necessary for the CMS/RAC Texas provider sessions, particularly the Webinar, to be cancelled?


A ray of sunshine, though: the Texas Hospital Association (THA) worked with CMS and Connolly, the RAC contractor, to develop a recorded Webinar (rather than a live one) for Texas constituents, and the bonus in all of this was that for several weeks in May providers were allowed to ask questions of both CMS and Connolly via the THA Web site. Let’s take a closer look at the responses to the questions that were asked and posted as of June 4.


Selected items from the Texas rollout FAQ include:


Previously audited accounts: If you notify the RAC it should be by phone, and e-mail should be used only if there is no reference to PHI.


Recoupments and cost reports: An inquiry regarding prior cost reports, if they must be re-opened based on findings, is labeled as PENDING. Stay tuned, as this is an important item.


Provider contacts: If a provider does not proactively identify a contact person for their RAC, all inquiries and requests will be made to the default billing information on file with the MAC.


Two-letter approach by the RAC: A review result letter will be the first correspondence from the RAC indicating whether or not an improper payment was found, however, it will not include any dollar amount or appeal rights, which will be included in the second DEMAND letter.


Discussion period contacts: A demand or review result letter will contain the reviewer’s name and contact information in order to initiate a discussion.


Crossing state lines: For providers with facilities in multiple states, the designated RAC will be based upon the FI or MAC that processes your claims.


How many NPI numbers to report: With regard to a hospital that has multiple NPI numbers for freestanding OP radiology or sports medicine clinics, all NPI numbers must be provided to the RAC.


Interest rate: A provider can avoid the accrual of interest by making payment to the FI/MAC directly prior to the 30th day (the current CMS interest rate is 12 percent). It also was clarified that the interest calculation does not stop during the discussion period.


Medical necessity criteria: Connolly will use Milliman as its screen tool for inpatient hospital reviews, but always will apply any CMS rules, policies and/or guidelines.


Medical record requests per NPI: CMS’s intent is to have all departments of a facility under an aggregate medical record limit; providers must notify the RAC of appropriate NPIs, tax IDs, etc. so that these limits can be applied appropriately.


Medical record limits for therapists in private practice: Yours truly is pleased to announce an answer to the often-asked (but until now, unanswered) question of how the medical record limits for physical, occupational and speech therapists in private practice are calculated.  It will be based upon the same methodology as the Part B limits for physician groups.


Medical records submission via CD/DVD: A detailed list of Connolly’s requirements for the electronic submission of medical records is posted at the THA Web site: Prior to submitting medical records via CD/DVD, providers should begin a validation process, keeping in mind that if any part of the process does not pass validation, the entire CD or DVD will be rejected. The validation process can be started immediately, according to Connolly; once the validation process is completed it will send an e-mail notification of a pass or a reason for a failure. Once the validation process is successful, providers should continue to follow the process as noted in guidelines referenced above.


Beneficiary communication: The RAC will not provide any beneficiary communication, which will be handled in the same fashion as the FI/MAC process.


Five-day presumption: For level 2 appeals or redeterminations, an answer to a question regarding the five-day presumption is PENDING. Stay tuned.


Extrapolation review: It was clarified that extrapolation refers to projecting a larger universe of claims with a statistically valid sample of improper payments. The CMS reference on this is in the Program Integrity Manual, Chapter 3, Section 10.


It is likely that all providers in Region C will benefit from the Texas FAQ, which provides helpful information to other providers on elements of the recovery audit contractor process that all RAC contractors must follow. Stay tuned for the next segment when a key risk for skilled nursing facilities is discussed.


Reference: All items were taken from the FAQ answers at the THA Web site. The full article may be accessed at:


About the Author

Nancy Beckley is co-founder and president of Bloomingdale Consulting Group, Inc., which provides consulting services to rehab professionals. Nancy is certified in healthcare compliance by the Healthcare Compliance Board and serves on the Part A and Part B Provider Outreach Education and Advisory Panel for First Coast Services Options (Florida Medicare). She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities.

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