This article highlights key similarities and differences and may not include all RAC region request forms posted or not posted on their Web sites.
You’ve Got Mail
In general, there are three separate letters that hospital providers can expect to receive from RAC Region A. The logo of the Centers for Medicare & Medicaid Services (CMS) is at the top of the letter and the RAC’s logo may be either at the top or the bottom of the letter. The links at the end of the article will link to sample request forms specific to each RAC region.
Additional Documentation Request (ADR). In the ADR, RACs request records for complex review because their data analyses indicate potentially incorrect billing and improper payment. In three out of four cases, documentation must include the complete medical record including physician query documents, ICD-9-CM coding summary sheet, and UB-04. (The exception is Region C, which does not request UB-04.)
Attached to the request is a listing of accounts required for submission within 45 days of the date on the letter. RACs will reimburse hospital providers for copying fees. Instructions for how to correctly submit paper document or CD/DVD electronic documents are included. A copy of the Additional Document Request form and account listing form must be attached to the copied documentation.
Demand Letter. With this communication, RACs notify hospital providers of the outcomes, overpayments or underpayments, and due dates of complex or automated reviews. This letter identifies whether the overpayment (or underpayment) was identified through additional documentation request (complex review) or through data analysis.
The letter specifically provides key timeframes for the rebuttal process (15 days from the date of the demand letter) and reiterates that the rebuttal process is separate from the discussion period. At 30 days, the instructions for repayment plans are provided, interest assessment at 31 days, and information for those in bankruptcy. At 40 days, Medicare will begin withholding Medicare payments, which applies to current and future claims until the full overpayment amount and any applicable interest has been recouped or an acceptable extended repayment request is received.
The instructions proceed to inform the provider how to stop recoupment. The first occurs if Medicare receives a valid and timely request for a redetermination within 30 days from the date of the demand letter. If the appeal is filed later than 30 days, the RAC will also stop recoupment at whatever point that an appeal is received, but Medicare may not refund any recoupment already taken. Appeals must be filed within 120 days. There are multiple levels of appeal, starting with the “redetermination-the first level. It must be filed within 120 days of the date of the demand letter.
However, if the hospital provider wishes to avoid the occurrence of recoupment and interest assessment on the overpayment, it needs to file a request for redetermination within 30 days from the date of this letter.
Request to Open Discussion Period. When a hospital provider wants to discuss a case or cases with its RAC, it will send a request to open discussion period. For automated audits, one form per issue must be submitted and a copy of the demand letter as well as the overpayment report page must be attached. Be sure to circle the claims that you want to discuss. For complex audits, submit one form for each decision and attach a copy of the RAC Review Results Letter for the case file in question. The information may be mailed or faxed.
RAC Region A – DCS
No variations identified.
Envelop has DCS and Centers for Medicare and Medicaid Services in return address with red printing “Immediate Response Required” RAC Correspondence Enclosed.
To access the Region A RAC’s sample letters, go to http://www.dcsrac.com/sample.html (Region A – DCS.
RAC Region B – CGI
The sample letter provided by XXXX, the Region B RAC, notifies hospital providers when it did not receive medical records and when it initiated the payment denial process and overpayment-recoupment plans. A separate letter is sent for all overpayment (and underpayment) findings as well as a separate letter when no findings are identified. There was no sample form attached to describe the process for the discussion period.
The envelope has CGI in a red font and CMS in a black font in the return address with “dated materials enclosed” marked on the envelope, also in red font.
http://racb.cgi.com/Letters.aspx (Region B – CGI)
RAC Region C – Connolly
This RAC does not include the “request to open discussion period” sample form in its options. Otherwise no other variations were noted.
RAC Region D – Health Data Insights
The “request to open discussion period” sample form may be initiated by fax or mail by submitting one form for each claim. Directions indicate that the provider should enclose a copy of the audit detail, and the RAC will review and submit a written response.
https://racinfo.healthdatainsights.com/Public1/ProviderInfo.aspx (Region D – Health Data Insights
About the Author
Carol Spencer, RHIA, CCS, CHDA is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with coding, chargemaster, reimbursement management and RAC solutions.
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