Recovery Audit Contractors (RACs)  Medicare, Medicaid and Commercial Insurance  What you Need to Know Med-Billing Solution...
Introduction <ul><li>Med-Billing Solutions, LLC </li></ul><ul><li>Stephen St. Gelais, Owner/ Consultant </li></ul><ul><li>...
Introduction Dedicated to serving the medical community Information Technology Terry Schladetzky Banking & Finance Alice M...
Med-Billing Solutions, LLC Providers Coding Resource Agenda  <ul><li>What is the RAC? </li></ul><ul><li>How does the RAC a...
What is the RAC? <ul><li>R ecovery  A udit  C ontractor (RAC) </li></ul><ul><li>Independent contractors, hired by CMS, aut...
RAC Mission <ul><li>“ Ensure integrity of Medicare Fee For Service claims through the identification and correction of imp...
Recovery Audit Contract-”RAC” <ul><li>4 (Four) Private firms to perform medical records and billing audits on providers in...
Regions and timelines *RACs are required to perform  outreach programs for all providers in their region From CMS D C B A ...
HealthDataInsights  – RAC Auditor <ul><li>https://racinfo.healthdatainsights.com/home.aspx   </li></ul>
RAC contingency fee % <ul><li>RACs are paid on a contingency fee payment basis </li></ul><ul><li>Based on the amount of th...
How the RAC affects the Provider If the providers bill  Fee-for-Service  Medicare, Medicaid or Commercial Insurance progra...
What about the other entities <ul><li>Medicaid/Medi-Cal ( partially funded by the federal government and managed by each s...
Private Insurance <ul><li>Aetna and other insurance carriers are pursuing the RAC process as well </li></ul><ul><li>WHY? <...
What does the RAC do? <ul><li>Review claims and medical records on a post payment basis  </li></ul><ul><li>Review claims p...
Who Oversees the RAC? <ul><li>The RVC ( RAC Validation Contractor) </li></ul><ul><li>Independent third party review entity...
Evaluation and Management (E/M) <ul><li>Major RAC Findings </li></ul><ul><li>Medicare’s global surgery payment rules even ...
Importance of Documentation Compliance <ul><li>The medical record or chart notes  must  match the codes you submit </li></...
RAC Claims Audit Process Overview <ul><li>Claims Audit  Process Phases </li></ul><ul><ul><li>Data Screening & Claim Select...
Automated review <ul><li>Example 1: Use information systems to find two or more identical surgical procedures for the same...
When the RAC arrives <ul><li>Physician provides a clear response to the letter within  45 days </li></ul><ul><li>Retain a ...
Fiscal Year 09 Medical Record Limits  <ul><li>Physicians </li></ul><ul><ul><ul><li>Single Practitioner : 10 medical record...
Collection Process <ul><li>RAC will issue a Demand letter </li></ul><ul><li>RAC will offer an opportunity for the provider...
Key Timeframes  (15, 30, 40, 120) <ul><li>15 Days:     </li></ul><ul><ul><li>Rebuttal process (Recoupment challenge) </li>...
What to Expect Next <ul><li>The RAC  will repeat  the exact same process  every 45 days  until they find no more overpayme...
How to Prepare Your Practice <ul><li>Perform  an  independent baseline audit  assessment to identify areas of non-complian...
MBS Support Base-Line Audit Process Medicare Documentation & Coding Benchmark Audit <ul><li>Random selection of 50 office ...
Beyond the Base-Line Review <ul><li>Billing team must track all denied claims </li></ul><ul><li>Identify all the issues </...
Review <ul><li>The RAC is to be taken seriously </li></ul><ul><li>The RAC can have a severe negative impact to an unprepar...
Services <ul><li>Med-Billing Solutions, LLC </li></ul><ul><li>Services:  </li></ul><ul><li>EMR i-Billing : Full Service, S...
Thank You <ul><li>Med-Billing Solutions, LLC </li></ul><ul><li>Stephen St. Gelais </li></ul><ul><li>MBS Consultant </li></...
Introduction Dedicated to serving the medical community Information Technology Terry Schladetzky Banking & Finance Alice M...
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The RAC's are coming: Is your medical practice prepared?

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Important notice to Medical providers/ Hospitals: starting in 2010, CMS (Medicare) has hired four RAC (Recovery Audit Contractors) to pursue claim billing violations. Their mission is to collect as many $$$ in overpayments as possible nationwide. They\\’re heavily incentivize (17% of what they collect). This presentation provides an overview of the RAC program as well as our baseline audit service to help protect you against the impending RACs

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The RAC's are coming: Is your medical practice prepared?

  1. 1. Recovery Audit Contractors (RACs) Medicare, Medicaid and Commercial Insurance What you Need to Know Med-Billing Solutions, LLC
  2. 2. Introduction <ul><li>Med-Billing Solutions, LLC </li></ul><ul><li>Stephen St. Gelais, Owner/ Consultant </li></ul><ul><li>Part of a nationwide network of over 1500 independently operated offices; established in 1994 </li></ul><ul><li>We specialize in assisting medical providers nationwide with enhancing their cash-flow , profitability and office productivity . </li></ul><ul><li>We accomplish this through a variety of our proprietary state-of-the-art billing solutions services. </li></ul><ul><li>Our Core Service Focus </li></ul><ul><li>#1 Responsibility : Insure we're capturing the workload documentation you have performed with your patients </li></ul><ul><li>#1 Goal: Assure that you're receiving the maximum revenue you're entitled by optimizing your &quot;RVU&quot; (Relative Value Unit). </li></ul><ul><li>#1 Priority: &quot;Denial Management“ </li></ul>
  3. 3. Introduction Dedicated to serving the medical community Information Technology Terry Schladetzky Banking & Finance Alice Madrid-Neumann Real Estate Linda Brown Business Brokerage Robert Fiance Flagship Charity: &quot;OwieBowWowie and Friends Foundation” Gina Gippner-Woods Joining us soon – Legal, Medical Waste, Construction and more… Marketing & Advertising Bob Charney Certified Public Acct. Kristine Vail Financial Services Edward Albrecht Medical Billing & Coding Stephen St. Gelais
  4. 4. Med-Billing Solutions, LLC Providers Coding Resource Agenda <ul><li>What is the RAC? </li></ul><ul><li>How does the RAC affect providers? </li></ul><ul><li>What does the RAC do? </li></ul><ul><li>Who oversees the RAC? </li></ul><ul><li>Major RAC findings/ Compliance </li></ul><ul><li>RAC process (what to expect) </li></ul><ul><li>How do Providers Prepare? </li></ul>
  5. 5. What is the RAC? <ul><li>R ecovery A udit C ontractor (RAC) </li></ul><ul><li>Independent contractors, hired by CMS, authorized by Congress </li></ul><ul><li>3 state pilot program in place since 2003 (hospitals only)– over $1B of overpayments collected </li></ul><ul><li>RAC objectives: </li></ul><ul><ul><ul><li>Documentation and coding inconsistencies </li></ul></ul></ul><ul><ul><ul><li>Overpayments (& Underpayments) made to the providers based on the findings </li></ul></ul></ul><ul><ul><ul><li>Clear documentation to support the medical necessity of the services being provided or dispensed </li></ul></ul></ul>
  6. 6. RAC Mission <ul><li>“ Ensure integrity of Medicare Fee For Service claims through the identification and correction of improper payments. Protect Medicare Trust Fund, prevent fraud, abuse and waste” – CMS </li></ul><ul><li>Tax Relief and Healthcare Act of 2006, Section 302 requires a permanent & nationwide RAC by 1/1/2010 to protect Medicare trust funds. </li></ul>
  7. 7. Recovery Audit Contract-”RAC” <ul><li>4 (Four) Private firms to perform medical records and billing audits on providers in all 50 states and Puerto Rico </li></ul><ul><ul><li>Provider types targeted </li></ul></ul><ul><ul><ul><li>Inpatient Rehabilitation Facilities </li></ul></ul></ul><ul><ul><ul><li>Hospitals </li></ul></ul></ul><ul><ul><ul><li>Physicians (especially high ticket services) </li></ul></ul></ul><ul><ul><ul><li>Skilled nursing facilities </li></ul></ul></ul><ul><ul><ul><li>Durable medical equipment suppliers </li></ul></ul></ul><ul><ul><ul><li>Laboratories, Ambulance, Other </li></ul></ul></ul><ul><ul><ul><li>Home Health Agencies </li></ul></ul></ul><ul><ul><ul><li>Hospices </li></ul></ul></ul>
  8. 8. Regions and timelines *RACs are required to perform outreach programs for all providers in their region From CMS D C B A March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 March 1, 2009 August 1, 2009 August 1, 2009 August 1, 2009 Provider Outreach Claims Available for Analysis Earliest Correspondence
  9. 9. HealthDataInsights – RAC Auditor <ul><li>https://racinfo.healthdatainsights.com/home.aspx </li></ul>
  10. 10. RAC contingency fee % <ul><li>RACs are paid on a contingency fee payment basis </li></ul><ul><li>Based on the amount of the improper payments they collect </li></ul><ul><li>Both overpayments and underpayments. </li></ul><ul><li>RAC compensation 10-13% (on what they collect) </li></ul>Source: C MS http://www.cms.hhs.gov/RAC
  11. 11. How the RAC affects the Provider If the providers bill Fee-for-Service Medicare, Medicaid or Commercial Insurance programs, their claims will be subject to review by the investigators and auditors Not at risk: practices/ facilities with high % (70%+) Medicare HMO Advantage, Medicare prescription
  12. 12. What about the other entities <ul><li>Medicaid/Medi-Cal ( partially funded by the federal government and managed by each state ) </li></ul><ul><ul><li>They are hiring firms like Healthnet Federal Services to mimic the identical issues as the federal government </li></ul></ul><ul><li>RAC’s will work/ coordinate with Medicare and Medicaid fraud teams: </li></ul><ul><ul><li>PSC: Program Safeguard Contractor </li></ul></ul><ul><ul><li>ZPIC: Zone Program Integrity Contractor </li></ul></ul>
  13. 13. Private Insurance <ul><li>Aetna and other insurance carriers are pursuing the RAC process as well </li></ul><ul><li>WHY? </li></ul><ul><li>Because they have implied authority to review all providers claims </li></ul>
  14. 14. What does the RAC do? <ul><li>Review claims and medical records on a post payment basis </li></ul><ul><li>Review claims paid after October 1, 2007 </li></ul><ul><li>RACs will be able to review medical records three years from the date the claim were paid </li></ul><ul><li>Collect overpaid claims paid </li></ul>
  15. 15. Who Oversees the RAC? <ul><li>The RVC ( RAC Validation Contractor) </li></ul><ul><li>Independent third party review entity to work with CMS to provide additional oversight </li></ul><ul><li>Ensure the RACs are making accurate claim determinations in the permanent program. </li></ul><ul><li>CMS announced it hired Provider Resources, Inc. of Erie, PA as the RVC </li></ul>Source: C MS http://www.cms.hhs.gov/RAC
  16. 16. Evaluation and Management (E/M) <ul><li>Major RAC Findings </li></ul><ul><li>Medicare’s global surgery payment rules even in cases involving E/M services. </li></ul><ul><li>E/M services that are not reasonable & necessary. </li></ul><ul><li>Duplicate E&M codes (results in overpayment) </li></ul><ul><li>New vs. established (patient) E&M codes </li></ul><ul><li>Units of service (injections) </li></ul>
  17. 17. Importance of Documentation Compliance <ul><li>The medical record or chart notes must match the codes you submit </li></ul><ul><ul><ul><li>Evaluation & Management (office visit) </li></ul></ul></ul><ul><ul><ul><li>Diagnosis </li></ul></ul></ul><ul><ul><ul><li>Injections </li></ul></ul></ul><ul><ul><ul><li>Supplies </li></ul></ul></ul><ul><li>Medical Necessity must clearly state the need for all services provided or prescribed. </li></ul>
  18. 18. RAC Claims Audit Process Overview <ul><li>Claims Audit Process Phases </li></ul><ul><ul><li>Data Screening & Claim Selection </li></ul></ul><ul><ul><li>Medical Record Request </li></ul></ul><ul><ul><li>III. Record Review and Status Determination </li></ul></ul><ul><ul><li>IV. Post Review Notification </li></ul></ul><ul><ul><li>Overpayment Recoupment </li></ul></ul><ul><ul><li>Post Determination </li></ul></ul>
  19. 19. Automated review <ul><li>Example 1: Use information systems to find two or more identical surgical procedures for the same beneficiary on the same day at the same hospital. (Medicare claims editor systems can identify these prior to billing.) </li></ul>Detects clearly improper Payments (overpayment or underpayment determination) without evaluating the medical record associated with the claim. Source: C MS http://www.cms.hhs.gov/RAC
  20. 20. When the RAC arrives <ul><li>Physician provides a clear response to the letter within 45 days </li></ul><ul><li>Retain a certified coder - review the records prior to submission </li></ul><ul><li>Send copies of the charts to the RAC- signature required notification of receipt. </li></ul><ul><li>Digitized/electronic file of your charts and supporting documentation. </li></ul><ul><li>WATCH THE MAIL FOR A RESPONSE </li></ul>
  21. 21. Fiscal Year 09 Medical Record Limits <ul><li>Physicians </li></ul><ul><ul><ul><li>Single Practitioner : 10 medical records per 45 days per NPI </li></ul></ul></ul><ul><ul><ul><li>Partnerships 2-5 individuals: 20 medical records per 45 days per NPI </li></ul></ul></ul><ul><ul><ul><li>Groups 6-15 individuals: 30 medical records per 45 days per NPI </li></ul></ul></ul><ul><ul><ul><li>Large Group Practices 16+ individuals: 50 medical records per 45 days per NPI </li></ul></ul></ul><ul><li>Other Part B Billers (DME, Labs) </li></ul><ul><ul><ul><li>1% of the average monthly Medicare claims (max 200) per NPI per 45 days </li></ul></ul></ul>
  22. 22. Collection Process <ul><li>RAC will issue a Demand letter </li></ul><ul><li>RAC will offer an opportunity for the provider to appeal the decision </li></ul><ul><li>Recoups by offset unless provider has submitted a check or a valid appeal </li></ul><ul><li>Providers HAVE NO CHOICE… </li></ul><ul><li>THEY TAKE THE $$ DIRECTLY FROM YOUR MEDICARE CHECK </li></ul>
  23. 23. Key Timeframes (15, 30, 40, 120) <ul><li>15 Days: </li></ul><ul><ul><li>Rebuttal process (Recoupment challenge) </li></ul></ul><ul><li>30 Days: </li></ul><ul><ul><li>Repayment Plans (Interest @12% starts on day 31) </li></ul></ul><ul><li>40 Days: </li></ul><ul><ul><li>Recoupment process begins on 41 st day </li></ul></ul><ul><li>120 Days: </li></ul><ul><ul><li>Appeals must be filed </li></ul></ul>
  24. 24. What to Expect Next <ul><li>The RAC will repeat the exact same process every 45 days until they find no more overpayments </li></ul>
  25. 25. How to Prepare Your Practice <ul><li>Perform an independent baseline audit assessment to identify areas of non-compliance with Medicare/Medicaid rules </li></ul><ul><li>Identify any corrective actions required for compliance </li></ul><ul><li>Implement any required changes to stay in compliance </li></ul><ul><li>Establish “Go-To-Team” – RAC Consultant & Certified Coders </li></ul>
  26. 26. MBS Support Base-Line Audit Process Medicare Documentation & Coding Benchmark Audit <ul><li>Random selection of 50 office notes </li></ul>Fax to HIPAA secure site (iDocumentsNow) for certified coders to review Documentation and coding Compliance audit performed by certified coders Web-based Training Audit Report <ul><li>MBS – Your “go-to” team </li></ul><ul><li>RAC Audit Management </li></ul><ul><li>RAC Findings Review </li></ul><ul><li>RAC Appeal </li></ul><ul><li>All Medical Specialties </li></ul><ul><ul><li>Designed for Physician </li></ul></ul><ul><li>Training for your coding team/ staff </li></ul>
  27. 27. Beyond the Base-Line Review <ul><li>Billing team must track all denied claims </li></ul><ul><li>Identify all the issues </li></ul><ul><li>Look for patterns </li></ul><ul><li>Deploy any corrective actions to avoid improper payments </li></ul>
  28. 28. Review <ul><li>The RAC is to be taken seriously </li></ul><ul><li>The RAC can have a severe negative impact to an unprepared Practice – both financially and disruptive </li></ul><ul><li>Once started, The RAC repeats the process every 45 days – they won’t stop until they’re convinced there are no more violations </li></ul><ul><li>Medicare is NOT likely to be the only payer going to take a peek ( private insurance, Medicaid/ Medical) </li></ul><ul><li>Know where you stand - Have a Base-Line Audit done </li></ul><ul><li>When the RAC arrives….. </li></ul><ul><li>Let MBS be your “Go-To Team” </li></ul>
  29. 29. Services <ul><li>Med-Billing Solutions, LLC </li></ul><ul><li>Services: </li></ul><ul><li>EMR i-Billing : Full Service, State-of-the-Art </li></ul><ul><li>EMR i-Solutions : One-stop solution </li></ul><ul><li>RAC Base-Line Audit Services </li></ul><ul><li>RVU-MAX - Coding Services (24-Hour) </li></ul><ul><li>MaxCollect™ Profit Recovery </li></ul><ul><li>Cash Flow Solutions </li></ul>Complimentary Practice Analysis
  30. 30. Thank You <ul><li>Med-Billing Solutions, LLC </li></ul><ul><li>Stephen St. Gelais </li></ul><ul><li>MBS Consultant </li></ul><ul><li>805-428-4566 </li></ul><ul><li>[email_address] </li></ul><ul><li>www.med-billingsolutions.com </li></ul>Med-Billing Solutions, LLC Providers Coding Resource
  31. 31. Introduction Dedicated to serving the medical community Information Technology Terry Schladetzky Banking & Finance Alice Madrid-Neumann Real Estate Linda Brown Business Brokerage Robert Fiance Flagship Charity: &quot;OwieBowWowie and Friends Foundation” Gina Gippner-Woods Joining us soon – Legal, Medical Waste, Construction and more… Marketing & Advertising Bob Charney Certified Public Acct. Kristine Vail Financial Services Edward Albrecht Medical Billing & Coding Stephen St. Gelais

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