September 21, 2009

If you have not yet discovered the Frequently Asked Questions (FAQs) feature of the Centers for Medicare and Medicaid website (www.cms.hhs.gov), you are overlooking an increasingly valuable tool. As of September 18, 2009, when the three most recent answers were posted, there were 1917 questions and answers ranging from the most basic “What is CMS?” to the quite esoteric. Entering a search term like “PQRI” or “EHR” will bring up a list of 88 or 58 questions respectively. To illustrate the types of information appearing under “Frequently Asked Questions” on the “Tools” tab on the website, we have selected a “top ten” list of FAQs on the Recovery Audit Contractor (RAC) program:

1. Question: What is the name and contact information for each RAC?
   Answer:
   1. Region A: Diversified Collection Services (DCS) -1-866-201-0580, www.dcsrac.com
   2. Region B: CGI -1-877-316-7222, e-mail: racb@cgi.com, http://racb.cgi.com
   3. Region C: Connolly Consulting, Inc. -1-866-360-2507, www.connollyhealthcare.com/RAC, RACinfo@connollyhealthcare.com
   4. Region D: HealthDataInsights, Inc. Part B: 866-376-2319, e-mail: racinfo@emailhdi.com
2. Question: How will the RACs determine which claims to review?
   Answer: The RACs will use their own proprietary software and systems as well as their knowledge of Medicare rules and regulations to determine what areas to review.
    
3. Question: How are the RACs paid for finding and recovering overpayments? For underpayments?
   Answer: RACs are paid on a contingency basis (i.e., they retain a portion of the monies recovered) for all accurately identified overpayments. They are paid on a percentage basis for all underpayments identified and recovered.
    
4. Question: Do RACs look for underpayments? What happens if they find an underpaid claim?
   Answer:Yes, RACs will identify underpayments as well as overpayments. In situations where a RAC identifies both overpayments and underpayments for a provider, the RACs offset the underpayment from the overpayment. In situations where a RAC identifies an underpayment for which there is no overpayment from which to offset, the RAC will inform the carrier or intermediary who will proceed with the claim adjustment and payment to the provider.

   A MLN Matters article, SE0617, was released on 04/10/2006 with additional information for providers concerning the identification of an underpayment by a RAC. The MLN Matters article can be found at www.cms.hhs.gov/MLNMattersArticles/download/SE0617.pdf.

5. Question: Under what circumstances will a RACs request medical records in order to determine if an overpayment exists?
   Answer: RACs must use complex review (where medical records ARE involved in the review) in situations where there is a high probability (but not certainty) that the claim contains an overpayment.
    
6. Question: Under what circumstances can a RAC make a finding that an overpayment or underpayment exists without requesting medical records?
   Answer:RACs may use automated review (where NO medical record is involved in the review) ONLY in situations where there is certainty that the claim contains an overpayment. Automated review must:
   1. have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment);
   • be based on a medically unbelievable service; or
   • occur when no timely response is received in response to a medical record.
      
7. Question: Will the RACs replace all current review entities?
   Answer: No. Other entities such as Medicare contractors (e.g., Carriers), Program Safeguard Contractors, Office of Inspector General or Quality Improvement Organizations (QIO) could still review a provider’s claims. The RACs will not review a claim that has previously been reviewed by another entity.
    
8. Question: Will CMS use calendar days or business days when determining the number of days a provider has to submit medical records?
   Answer: CMS will utilize Calendar Days when making these determinations.
    
9. Question: How long does a provider have to submit medical records when requested by a RAC?
   Answer: Providers must respond within 45 days to a RAC request for medical records. Providers may request an extension at any time prior to the 45th day by contacting the RAC.
    
10. Question: If a provider repays or Medicare recoups an alleged overpayment identified by the RACs and the provider later wins an appeal, will CMS reimburse the provider with interest?
    Answer: At certain times, CMS is required to pay interest when an appeal decision is favorable to the provider. The payment of interest in response to a favorable provider appeal decision is determined by CMS' interpretations of the appeal regulations. These regulations determine the process for all overpayments, not just RAC identified overpayments

The answers to some of the FAQs above appear rather summary and/or general, but they include a list of related questions that can be quite productive. For example, the question “How can people get more information about the Electronic Health Records Demonstration?” is followed not just by the answer:

“More information about the Electronic Health Records Demonstration can be found on the demonstration web site at:

http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/
2008_Electronic_Health_Records_Demonstration.pdf

. There are links on the above web site to each of the community partner's web sites where site-specific information may be found. Questions about the demonstration can be sent to:

EHR_Demo@cms.hhs.gov

(Note the underscore between "EHR" and "Demo.")

but also by these possibly related FAQs:

• How do providers obtain an application for the Electronic Health Records Demonstration?
• What is the Electronic Health Records Demonstration, and why are you doing it?
• When will the Electronic Health Records demonstration begin?
• How do you define a practice for purposes of enrolling in the Electronic Health Records (EHR) demonstration?
• When will the incentive payments start? How are the payments distributed? At the end of 5 years? Annually?

Note also the growing collection of “MLN Matters” white papers on topics such as RAC underpayments, referenced in RAC FAQ #4 above. These are one of the four major Medicare Learning Network products available on the Outreach & Education page. Last but definitely not least, consider the Anesthesiologists Center, a web page (http://www.cms.hhs.gov/center/anesth.asp) dedicated to the specialty, where you can find anesthesia billing rules and conversion factors, among other information.

These Medicare resources are where we go to find the answers to our own and our clients’ questions. We recommend that you familiarize yourself with CMS’s physician education tools – and that you help to make them even more useful by submitting your own questions to CMS.

With best wishes,

Tony Mira
President and CEO