Contact information – CGI will receive a data file over a secured data line from each MAC/FI carrier containing facility/provider information. CGI will use this contact information UNLESS the provider supplies an update via e-mail or by contacting the CGI Call Center. DCS, on the other hand, will obtain provider contact information from the data supplied on their Web pages, or via telephone, mail, e-mail or fax. They also will accept contact information provided by the provider associations. The HDI FAQ page was silent on this issue.
On-site audits -CGI’s determinations on whether to conduct an on-site audit will be made based on the scope as well as the volume of medical records to be reviewed. The audit team will consist of no more than two members. Neither DCS nor HDI address the issue of on-site reviews.
RAC Review Process and Timeline for Complex Reviews:
1. Documentation Request – The first notification from a RAC in the complex review process is the request for medical records, a.k.a. the Additional Documentation Request (ADR). CGI states that the provider has 45 days to provide medical record copies to the RAC in response to this request. DCS states that the provider has 45 days (plus 10 days for mailing) to provide the medical record copies. Additional time may be requested by contacting DCS or CGI. HDI does not provide any information on the documentation submission time frame, but does report that CMS is developing a medical record request/ADR letter. The other sites do not mention a specific format for this type of letter.
2. CGI will send out reminder notices if documentation has not been received prior to the 45-day deadline. The other RACs do not mention any reminder notification to providers. If the deadline is missed, the claim may be denied, according to CGI.
3. Submission of records electronically – CGI does not at this time address submission of records electronically. HDI will accept records submitted on an encrypted CD/DVD and will include instructions on the record request letter. The DCS Web site provides detailed instructions for submission of records electronically (as well as in paper format).
4. CGI and HDI state that they have 60 calendar days from receipt of medical records to review all documentation, make a claim determination and send the review results letter to the provider. The same will be true for the other RACs, as this timeline is noted in the scope of work.
5. Medical Necessity Criteria – CGI and DCS appear to differ in the criteria they will use for medical necessity. DCS states that they only will use Medicare’s legal and regulatory documents and policies, such as National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as guidelines for decision-making. They also may choose to utilize clinical support software products as screening tools, but, if they use such products, they will make information about the choice available to the community. CGI has indicated on their Web site that they will use McKesson (InterQual) criteria. They also state that they will use the rules for NCDs, LCDs, HCPCS, ICD-9 (ICD-10 when available) and correct coding initiatives.
6. Review Results Letters – Both DCS and CGI state that they will document the rationale for the determination of review findings with a detailed description of the Medicare policy that was violated. The review results letter will document all rationale for the claim determination, including the detailed description of the Medicare policy or rule that was violated and a statement as to whether the violation resulted in an improper payment. Depending on whether the determination is a full or partial denial, the overpayment amount is determined. Review results letters only are sent for complex reviews.
7. Discussion Period – Discussion periods are not addressed by any of the RACs. According to the DCS FAQ, the discussion period lasts until an issue is resolved or recoupment is complete. The time period between the receipt of the review results letter and the demand letter is not precisely defined. DCS will make every effort to forward the claim to the MAC at the same time the review results letter is sent out. Once the MAC has created the appropriate accounts receivable, it will inform DCS and the demand letter will be sent as soon as possible.
8. A provider has an initial discussion period to present additional information to support the services billed. If the provider does not agree with the decision, it has 120 days from the date of the first demand letter to file an appeal.
CGI will accept physician office notes to support the request for services. Providers are encouraged to submit all supporting documentation with the initial medical record request. During the initial discussion period, supporting evidence for a request for services will be accepted.
DCS notes that a provider will receive written results of a decision made in favor of the provider only upon request to the RAC.
9. Underpayments – While a provider cannot appeal an underpayment, CGI states that the provider may utilize the initial discussion period to present any concerns to the RAC. (NOTE: some attorneys recommend copying a regional office on any correspondence related to a dispute on underpayments).
HDI states that if a provider does not agree with an underpayment determination, it can serve notice that it does not wish to receive the money, and HDI will close the claim.
10. Demand Letters – Following the discussion period, if CGI still agrees that there has been an improper payment, the first demand letter will be sent. If no response to the first demand letter is received, a second demand letter shall be sent 30 days later. If overpayment has not been recouped and the debt is eligible for referral to the Department of Treasury, intent to refer to the Treasury and/or a third demand letter shall be sent to the provider 30 days after the second letter.
DCS will issue demand letters with multiple accounts on one letter for both complex and automated reviews, but it does not indicate that they will send multiple demand letters.
In summary, the general process for RAC reviews is similar, but there are currently differences in how the RACs will handle it. Keep checking your RAC’s Web site, as the information changes frequently.
About the Author
Cheryl E. Servais, MPH, RHIA, has more than 25 years of experience in health information management. In her position at Precyse Solutions, Ms. Servais’ responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the executive and board levels and takes an active role in professional organizations.
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