Medicare RAC Auditors Expand Coding, MS-DRG assurance and Medical Necessity Reviews. CMS Targets Providers Nationwide With Expanded Medicare Recovery Audits (RAC Audits)
In an effort to move-the-bar and collect on perceived overpayments to providers, The Centers for Medicare and Medicare Services (CMS) is taking aggressive strides to accelerate the acceptance of evidence-based health care and lighten the load of a strained national budget. After spending the past 30 years collecting and analyzing outcomes data from internal programs (CERTs, HPMPs, QIOs, etc.), both Congress and CMS have committed unprecedented resources to enforce evidence-based coverage policies and stop Medicare fraud.
In addition to the highly touted and widely publicized RAC Audits - Medicare ZPIC audits, OIG audits, DOJ audits, Medicaid Integrity Contractor audits and the Medicare One PI system are all just samples of the latest initiatives focused on provider payments. However, CMS is adopting Medicare recovery audits (or RAC audits) as the first real tangible effort to push hospitals, physicians and other healthcare providers down a path of revolutionizing the clinical practice of medicine. Using a classic "carrot and stick" approach, CMS has combined clinical pay-for-performance (P4P) incentives and value-based purchasing initiatives (the carrot) with the strong arm of RAC medical collection agencies (the stick) to insure providers are doing their part to facilitate a more nationalized, evidence-based healthcare structure.
How Can Jackson Davis Help?
As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in assisting healthcare providers facing Medicare compliance challenges. For over 25 years, Jackson Davis HealthCare professionals have dedicated every day to understanding, documenting, synthesizing and applying Medicare Coverage Criteria for cases being considered for Medicare audits and Medicare appeals - RAC appeals, ZPIC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.
Medicare Appeals (RAC appeals) / Medicare Shadow Audits - Over the past 25 years, Jackson Davis professionals have worked with providers nationwide to appeal 1,000s of Medicare overpayment issues and win close to 90% of all cases. JDH partners with providers to analyze, develop & build winning Medicare appeals cases. Our board-certified physicians, legal nurse auditors and industry-leading compliance staff are unmatched in Medicare audit defense and the submission of winning Medicare appeals. Simply put, NO ONE will give you a better chance to succeed at your Medicare appeals.
2013 Medicare Self-Audit Templates - Are you looking to build a rock-solid internal audit & compliance program using Medicare coverage criteria as a foundation? Have you been conditionally denied payment from a Medicare contractor and want to build winning appeals? The 2013 Medicare self-audit templates are perfect for use by internal auditors and compliance professionals when reviewing potential Medicare focus areas and building winning Medicare appeals. These detailed, self-audit templates are now available for purchase by healthcare providers nationwide.
Mock Medicare Program Integrity Audits (Mock PI Audits) - Jackson Davis HealthCare assists providers in completing proactive, medical records audits versus Medicare coverage criteria - Medicare Program Integrity audits (or "Mock" PI Audits). Each Medicare PI audit is based on documented, CMS payment criteria and Medicare coverage criteria for selected focus areas and may include a sampling of 10 - 500 patient encounters. Each encounter is pre-screened and carefully selected based upon Medicare current or anticipated audit focus areas.
Medicare "Additional Documentation Request" Response (RAC auditor ADR response) - A provider's initial ADR response is a critical stage of the Medicare audit process. Jackson Davis professionals are experts at developing a cohesive and winning approach to responding to RAC auditor requests for documentation. NO ONE will give you a better chance to address and eliminate additional Medicare audit threats.
Internal Audit & Medicare Physician Advisor Program Development - Are you looking for a helping hand in developing or revamping your internal audit or Medicare physician advisor programs? Are you looking for a reliable resource to work as a true partner in the process of adopting a more structured foundation built on Medicare coverage criteria? Are you uncomfortable about facing prepay audits or want peer review of your external physician advisor group? Jackson Davis is the solution. Our board-certified physicians really do understand Medicare coverage criteria and they work closely with our legal nurses and regulatory team to bring compliant solutions to providers everyday.
CMS Compliance Advisory Services - Providers nationwide retain JDH for monthly audits, compliance advice or on a project-by-project basis. Our staff is highly experienced and our knowledge and application of Medicare rules and regulations is unmatched in the industry. We are true Medicare compliance geeks. From our physicians to our nurses to our compliance research team, we are in your corner and available 24/7 for your CMS compliance needs. Call us today for help with any medicare appeal issue - hospital appeals, snf appeals, home health appeals, physician appeals, hospice appeals and DME supplier appeals.
Medicare Audits & Medicare Appeals - $295 Webcasts - FY 2013 Spring / Early Summer Events
Join our industry-leading Medicare audit defense team and Medicare coverage criteria professionals for the nation's best Medicare audits and Medicare appeals webcasts! Call or e-mail us today for registration at firstname.lastname@example.org or (303) 586-5003.
May 8, 2013 - 2:00p - 3:30p EST
Physician E & M Coding and Use of Modifier 25 - Inpatient / Outpatient Hospital and Physician Offices
This presentation will address a key focus area that is rolling out nationwide on the permanent Medicare audit program - Physician Evaluation & Management services & Use of Modifier 25 in both hospital and physician practice settings. Several previous Medicare audits, error evaluations, probes and directives have highlighted a wide range of challenges regarding the accuracy of E&M visit definitions. This discussion will provide an in-depth look at physician evaluation & management coding for inpatient hospitals services (CPT 99221 - 99223, 99231 - 99233) and established office visits (99211 - 99215).
Please send your registration request and contact information to us via e-mail at email@example.com. Registrations must be received no later than May 7 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
May 22, 2013 - 2:00p - 3:30p EST
Inpatient Rehabilitation Facility - 2013 Medicare Coverage Criteria
This presentation will address Medicare Coverage Criteria for Inpatient Rehabilitation Facility admissions. After a prolonged absence following the initial RAC demonstration project, Medicare and Medicare contractors are starting to "circle-back" to IRFs. We will discuss the IRF "medical necessity" criteria and the full range of CMS documentation requirements for inpatient rehab providers.
Please send your registration request and contact information to us via e-mail at firstname.lastname@example.org. Registrations must be received no later than May 21 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
June 5, 2013 - 2:00p - 3:30p EST
Home Health Agencies - Homebound Status, Certification, Skilled Nursing Care & Physical Therapy
This presentation will address Home Health Agencies and ramped up CMS efforts to attack perceived overpayments to providers. Nationwide, ZPICs, RACs and MACs are out in full force to conditionally deny cases based upon homebound status, lack of certification, unnecessary skilled nursing care and medically inappropriate physical therapy services. This is an OUTSTANDING presentation for home health providers and will focus on Medicare coverage criteria, responding to Medicare additional documentation requests and the filing of home health appeals.
Please send your registration request and contact information to us via e-mail at email@example.com. Registrations must be received no later than June 4 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
June 19, 2013 - 2:00p - 3:30p EST
The Medicare Appeals Process for Healthcare Providers - How to Win!
This presentation will address issues associated with Medicare audit defense strategies, Medicare appeals and Medicare shadow audits - RAC appeals, ZPIC appeals, DOJ appeals, OIG appeals, MAC appeals, Medicare overpayment determinations and the Medicare appeals process. Through 2013, Jackson Davis has assisted providers in winning almost 90% of all Medicare appeals... and we will be in your corner!
As CMS continues to ramp up auditing efforts, providers nationwide are spending tens of millions of dollars on legal fees, repaying hundreds of millions of dollars to CMS for conditional denials and being exposed to potential Medicare fraud allegations. This discussion will provide an in-depth look at the Medicare appeals process and explore a wide range of opportunities for providers to proactively build winning Medicare appeals (RAC appeals, ZPIC appeals, etc.). The old days of soft regulations and provider education are over - it is absolutely vital that providers understand how the game has changed.
Please send your registration request and contact information to us via e-mail at firstname.lastname@example.org. Registrations must be received no later than June 18 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
2013 Medicare Audit Defense & Medicare Appeals - Self-Audit Templates
Medicare self-audit templates and Medicare supporting documentation are now available for purchase by healthcare providers and healthcare attorneys nationwide. These are the perfect solution to proactively preparing for Medicare RAC audits, Medicare ZPIC audits, Medicaid Integrity Contractor audits and a wide range of other CMS audit initiatives!
Jackson Davis HealthCare, the nation's leading resource for Medicare audit defense & Medicare appeals, has invested thousands of hours in the documentation of CMS payment criteria, Medicare coverage criteria & development of Medicare self-audit templates for each RAC audit focus area. These Medicare self-audit templates are backed by over 10,000 CMS and CMS contractor documents and provide the nation's most comprehensive resource for the evaluation of Medicare audit focus areas and the preparation of Medicare appeals.
The Medicare self-audt templates are perfect for use by internal auditors and compliance professionals in proactively reviewing potential RAC audit cases and when considering the filing RAC appeals. The following is a small sample of Medicare self-audit templates that are available for purchase by healthcare providers:
PCI / ICD / Pacemakers (surgical procedures in wrong setting)
Major Joint Replacement (orthopedic hips / knees)
Home Health Agency admissions (homebound status and medical necessity)
Skilled Nursing Facility admissions
Short stays (chest pain & chest pain related diagnoses)
Pneumonia diagnosis code sequencing
Physician E&M coding
Hospice admissions (medical necessity)
Respiratory care with ventilator diagnosis code sequencing
Inpatient Rehabilitation Facility admissions
Outpatient physical therapy visits
Use of modifier 25
Wound care clinic and procedure billing
Emergency Room visit criteria and CPT code selection
HME supplies (billing and medical necessity)
Excisional Debridement Impacted MS-DRGs
Extensive O.R. Procedures Unrelated to PDX
Portable Radiology visits & billing
Neulasta billing & documentation
Septicemia diagnosis code sequencing
Single and multi-facility pricing options are available. Contact one of our Medicare audit defense team members or Medicare appeals compliance professionals with any questions and place your order request at (303) 586-5003 or e-mail us directly at email@example.com
A Little RAC History - The Demonstration Project
"If it's not documented, it’s not done” - this has been the mantra of every hospital HIM department head, Case Management professional and compliance officer for the past 20 years. Now both Medicare & Medicaid are adopting coverage criteria and evidence-based coverage policies, defining clinical payment criteria, replacing QIOs with RACs, forcing the issue of evidence-based outcomes, verifying supporting medical documentation and insuring claim payment levels. CMS has hired independent medical collection agencies - Recovery Audit Contractors (RACs) - to lead the way and they are paying 9% - 12.5% contingency fees to guarantee the outcome.
From 2005 - 2007, the Centers for Medicare and Medicaid Services (CMS) undertook the RAC demonstration project in Florida, New York, California (South Carolina, Massachusetts & Arizona were added late in 2007) while preparing for a nationwide roll out. In addition to an initial $36.2M in FY 2005, the RAC audits recovered $332.9M in FY 2006 and a staggering $610.9M in FY 2007 in overpayments to providers in the demonstration states. In addition to law enforcement efforts to stop Medicare fraud, CMS estimates billions of dollars in overpayments for patient services will be identified with the national RAC audit focus.
o Medicare RAC Audits - 2006 Status Report
o Medicare RAC Audits - 2007 Status Report
o Medicare RAC Audits - 2008 Summary Status Report
o Medicare RAC Audits - National Expansion Schedule
o Recovery Audit Program Overview - Legislation & Regulation
Based upon outcomes from the demonstration project and the Statement of Work for the nationwide audit program, RACs are clearly leveraging the prior work of their peers. Quality Improvement Organizations (QIOs), Comprehensive Error Rate Tests (CERTs) and the Hospital Payment Monitoring Program (HPMPs) all played a vital role in guiding the initial stages of the RAC audit process. As a result, over 95% of Medicare RAC audit identified overpayments have been directly related to CMS payment criteria, Medicare coverage criteria, ICD-9 coding assignments, evaluations of "medical necessity" and/or a need to meet Medicare Conditions of Participation documentation requirements (these are similar outcomes to other previous CMS audits).
It is critical that providers realize that Recovery Audit Contractors have the ability to analyze claims with payment dates reaching as far back as October 1, 2007. Providers should also be very aware of the potential Medicare fraud & abuse ramifications and consider that a wide range of whistleblower suits have been brought in RAC audit related focus areas.
RACs are focusing on picking the low-hanging-fruit and reaching deep into the pockets of hospitals, inpatient rehabilitation facilities and physician practices. These are areas such as "inappropriate" admissions for invasive cardiology procedures (such as ICDs, pacemakers and PCIs) where CMS and Medicare coverage criteria have been codified and in place for several years. However, RAC auditors and CMS are also dedicated to implementing a systematic methodology to insure absolute and ongoing provider adherence to Medicare coverage criteria as defined by CMS manuals, National Coverage Determinations, Local Coverage Determinations, QIO guidelines, etc..
Under the program, RAC audits focus on established CMS payment criteria / Medicare coverage criteria and consist of both automated claims history reviews from the CMS database as well as complex clinical reviews of patient medical records. Specific areas of concentration include those similar to CMS audits such as Medicare ZPIC audits and Medicaid Integrity Contractor audits (MIC audits) - "not medically necessary services" (or those not meeting CMS evidence-based coverage criteria), non-covered services, incorrectly coded claims, duplicate services and incorrect payment amounts.
For assistance with RAC appeals (or any other Medicare appeals) - or for any other questions regarding CMS efforts to stop Medicare fraud & abuse, Medicare audits, Medicare appeals or Medicare RAC appeals - please contact us at (303) 586-5003 or firstname.lastname@example.org.
Medicare Recovery Audits - A Brief Chronology
August 12, 2010 - After 2 years of delays and contract challenges relating to the Medicare Recovery Audit program, CMS has approved the in-depth "medical necessity" review of multiple evidence-based coverage areas. Initially, the focus will be on the admission of patients with chest pain and chest pain related diagnoses (primarily MS-DRG 312 and MS-DRG 313). Jackson Davis has been working with providers nationwide over the past several years to implement Medicare coverage criteria for chest pain cases.
December 2, 2009 - Connolly HealthCare was approved by CMS to initiate the auditing of 24 new issues this week in Region C. These issues specific relate to MS-DRG focus areas and claim submission issues. CRMG has scheduled an education webcast for January 5, 2010 to discuss and review billing and claim submission issues relating to Extensive O.R. Procedures Unrelated to the Primary Diagnosis - MSDRGs 981 - 983.
November 15, 2009 - Hospitals throughout the southeast reportedly started receiving denials this week from Connolly HealthCare relating to a wide range of automated audit issues.
November 12, 2009 - The Obama administration and CMS started an aggressive rollout of fraud related public relations articles and specifically highlighted outcomes from recent law enforcement investigations. Based upon the scope and direction of the governmental reports (as well as the imminent adoption of healthcare reform), CRMG expects unprecedented growth in law enforcement activities throughout 2010 aimed at perceived provider fraud & abuse.
August 3, 2009 - Today, Connolly Healthcare posted the first list of CMS approved issues relating to automated RAC audits. Seven CMS payment criteria issues have been initially approved for automated audits in South Carolina and are expected to be quickly approved for the remaining states located in RAC Region C. Designated the "unlucky 7", this first round of CMS approved RAC issues includes Blood Transfusions, Untimed Codes (most likely Physical Therapy initial and re-evaluation codes), IV Hydration Therapy, Bronchoscopy, once in a lifetime procedures, pediatric procedures and Pegphilgrastim injection codes.
An overview of the initial Medicare RAC audits "Unlucky 7" can be found on the RAC audits section of the Connolly Healthcare website.
June 28, 2009 - Tim Johnson, Executive Director for the Castle Rock Medical Group, was asked to present a RAC audits & appeals update to the TxHIMA annual convention in Dallas and were joined by Jackson Walker, L.L.P. (one of Texas' leading health law firms). Castle Rock Medical Group and Jackson Walker would like to thank TxHIMA and the Texas hospital representatives for a terrific session and unsurpassed hospitality.
May 1, 2009 - CMS has posted an update to the RAC Audit and RAC Appeals education schedule for the state of Texas. The Texas Hospital Association (THA), CMS and Connolly Consulting have canceled the "live" sessions and this information is being be made available by THA through their website.
March 19, 2009 - CMS has announced the tentative outreach schedule for state-by-state provider RAC audit & RAC appeals education. This outreach process was mandated as part of the national roll out and is designed to offer additional insight and respond to provider questions relating to the program.
February 6, 2009 - The Centers for Medicare & Medicaid Services (CMS) announced the settlement of RAC audit protests by both PRG-Schultz and Viant. Based upon the settlement, PRG-Schultz and Viant will be retained as sub-contractors to the primary RACs in each region.
Important note to IRF providers and physicians: PRG-Schultz sub-contracted with Viant during the RAC audits demonstration project and they made a significant impact in challenging Inpatient Rehabilitation Facility (IRF) admissions throughout California ($59.7M in IRF admissions were denied in California).
February 6, 2009 - The Government Accountability Office (GAO) website was updated this morning to show that a resolution and settlement had been reached in conjunction with the RAC contract award protests. Both protests have been "withdrawn" by PRG-Schultz and Viant - opening the door for the full national RAC audit rollout to commence effective immediately.
February 1, 2009 - The Government Accountability Office (GAO) continues its review of protests filed by PRG Schultz and Viant. Both organizations filed formal protests in connection with the permanent RAC awards and the GAO was required to initiate an automatic 100 day "stay" in the nationwide rollout of the RAC audit process. CRMG will continue to closely monitor the GAO review of the awards and give providers notice as soon as the GAO decision becomes available. The GAO decision to both protests is due the week of February 9, 2009.
January 5, 2009 - CMS released updated information on recovery audit appeals activity through August 31, 2008 for the RAC audit demonstration states. According to CMS, RACs denied 525,000 claims (275,000 Part A and 250,000 Part B claims). Providers challenged 22.5% of RAC denials and filed 118,000 RAC audit appeals (57,000 Part A appeals and 61,000 Part B appeals). To date, providers have won approximately 40,000 RAC appeals or 34% of all cases filed for appeal.
November 28, 2008 - CMS released revisions to monthly statistical reporting for Medicare appeals activity reflected on form CMS-2592. Due to the anticipated level of RAC appeals and associated workload, CMS will be tracking separate statistics for RAC appeals versus other Medicare appeals. Specifically, this will allow CMS to more accurately allocate funds directly for RAC appeals activity.
November 14, 2008 - The December '08 issue of Eli's Research Report was released today and offers an in-depth look at CMS & RAC audit challenges to both inpatient and outpatient physical medicine providers. Inpatient rehabilitation providers were hit particularly hard during the demonstration project and have been facing intense RAC auditor reviews relating to the meeting of medical necessity criteria and documentation requirements.
November 12, 2008 - CMS held Special Open Door Forums for both Medicare Part A and Part B providers (November 12 and November 13) via teleconference to discuss a wide range of issues related to the national rollout of the RAC audits program. Several CMS professionals weighed-in during the discussion and reiterated previous CMS guidance relating to areas such as the RAC audit process, RAC medical records requests and RAC appeals.
November 4, 2008 - The Centers for Medicare and Medicaid Services (CMS) formally announced the protest of permanent RAC audit contracts by 2 unsuccessful bidders. PRG-Schultz and Viant both have filed protests with the General Accountability Office (GAO). With well over $100M in contingency fees at stake, both companies are fighting hard for their piece of the RAC collection agency pie. While the protests do result in an automatic 100 day reprieve from provider recoupment of overpayments, they do not impact the retroactive nature of the RAC process. Once finalized, the permanent Medicare recovery audit contractors will be reviewing and denying perceived overpayments back to October 1, 2007.
November 3, 2008 - After establishing and committing to the formal provider RAC audits outreach schedule nationwide, CMS had to cancel all meetings today due to a "protest and stay of performance" relating to the awarding of the permanent RAC contracts. While details are pending from CMS, this action was taken on behalf of PRG-Schultz (who's stock was down 65% since they lost the permanent RAC contract award: PRGX) who was clearly unhappy with a potential loss of over $100M in anticipated contingency fees from the permanent RAC project. PRG-Schultz gained the ire of providers throughout California during the demonstration project and their lack of participation in the permanent program was applauded by the California Hospital Association.
October 29, 2008 - CMS formally established limits for the number of medical record requests by the permanent RACs and outlined the methodology for complex review limitations. Basically, hospitals, inpatient rehab facilities and skilled nursing providers will be limited to the lower of 200 individual record requests or 10% of the provider's monthly claim volume - per 45 day period. Physician limitations are based upon the size of the practice and range from 10 to 50 medical records per 45 day period.
October 10, 2008 - CMS outlined the RAC audit contingency fee agreements for the Medicare Recovery Audit Contractors in each region. Ranging from 9% - 12.5%, CMS is paying independent RAC fees based upon the collection of perceived overpayments for services with paid claim dates starting October 1, 2007.
October 6, 2008 - CMS announced the 4 permanent RACs today and reaffirmed the immediate, rapid and comprehensive roll out of the Medicare Recovery Audit program nationwide. The permanent RACs have been initially assigned to 19 states and 4 different regions as the roll out begins nationwide. The remaining states will be assigned in early 2009 for implementation later next year (however, ALL states are subject to audit for paid claim dates back to October, 2007).
In conjunction with the formal press release and announcement today, CMS Acting Director Kerry Weems laid out an aggressive plan to combat perceived "fraud" and aggressively pursue provider recoupment nationwide. While much more information is anticipated over the next 30 - 60 days regarding the RACs and related contact information, the following permanent RACs are in place:
Region A - Diversified Collection Services, Inc. - Livermore , California
Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York
Region B - CGI Technologies and Solutions, Inc. - Fairfax, Virginia
Michigan, Indiana and Minnesota
Region C - Connolly Consulting Associates, Inc. - Wilton, Connecticut
South Carolina, Florida, Colorado and New Mexico
Region D - HealthDataInsights, Inc. - Las Vegas, Nevada
Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona
October 5, 2008 - In a press release dated today, PRG-Schultz announced that they received notice from CMS and have not been selected as a permanent RAC audits contractor under the Medicare Recovery Audit program. PRG-Schultz did receive a RAC audit contract during the demonstration period, but apparently their contingency % bid for the permanent program was too excessive.
September 12, 2008 - CMS released Transmittal 141 today and discussed revisions to the Medicare RAC appeals process and recoupment of perceived overpayments to providers. In summary, time frames relating to the first 2 steps in the RAC appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration). However, in order to stop the automated recoupment of overpayments from RAC audits, providers MUST file within 30 days for redetermination and within 60 days for reconsideration.
September 12, 2008 - CMS Office of Financial Management Director Tim Hill reaffirmed the selection of permanent RAC auditors and a revised time frame for the nationwide roll out at an AHA forum for hospital executives this week. Mr. Hill confirmed CMS' intention to announce the permanent RACs by October 1 and the initiation of demand letters and medical records request no later than January '09.