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Medicare >> Memorandum
To: State Execs, AHCA Finance Committee, Legal Committee, Reimbursement Task Force, and Advocacy Departmentt
From: Elise Smith
Subject: Update on CMS Recovery Audit Contractors (RAC) Program - As Of July 2009
Date: 7/14/2009

The following bullets provide basic information on the RACs, AHCA and CMS sources for further RAC information, and an update on current RAC activity.  For a wealth of substantive information on how RACs will operate, and how to prepare for RAC audits and mount appeals, please see the PowerPoint presentations from the AHCA Webinars, referred to below.    

  • RACs -- The RAC in each jurisdiction is as follows:
    • Region A:  Diversified Collection Services, Inc. of Livermore, CaliforniaRegion A  consists of the following states: Maine, New Hampshire, Massachusetts, Rhode Island, Connecticut, Vermont, New York, Pennsylvania, New Jersey, Delaware, Maryland, District of Columbia
    • Region B:  CGI Technologies and Solutions, Inc. of Fairfax, Virginia – Region B  consists of the following states: Minnesota, Wisconsin, Michigan, Illinois, Indiana, Ohio, Kentucky
    • Region C:  Connolly Consulting Associates, Inc. of Wilton, Connecticut – Region C consists of the following states: Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Michigan, Alabama, Florida, South Carolina, North Carolina, Virginia, Tennessee, Georgia, West Virginia, Mississippi
    • Region D:  HealthDataInsights, Inc. of Las Vegas, Nevada – Region D  consists of the following states: Alaska, Washington, Oregon, California, Nevada, Idaho, Montana, Wyoming, Utah, Arizona, North Dakota, Hawaii, South Dakota, Nebraska, Kansas, Iowa, Montana, Missouri

CMS indicates that correspondence, websites and call centers will be in the name of the RACs above.  Thus, providers should consult both the RAC and CMS web sites frequently.     

  • Contact Information:  RAC Information, CMS Information and AHCA Information

RAC

Website

Email

Telephone Number

Region A: Diversified Collection Services

www.dcsrac.com

info@dcsrac.com

1‐866‐201‐0580

Region B: CGI

http://racb.cgi.com

racb@cgi.com

1‐877‐316‐7222

Region C: Connolly Consulting

www.connollyhealthcare.com/RAC

RACinfo@connollyhealthcare.com

1‐866‐360‐2507

Region D: HealthDataInsights

Not Operational Yet

racinfo@emailhdi.com

Part A: 866‐590‐5598
 Part B: 866‐376‐2319

CMS:    Two  two key sites for CMS information on the RACs are http://www.cms.hhs.gov/RAC  and http://www.cms.hhs.gov/RAC/03_RecentUpdates.asp#TopOfPage.  CMS provides updates on these sites and various extremely helpful documents as downloads.  See also sites for CMS issuances at the end of this memo.

AHCA:  AHCA provided four webinars in the spring and summer of 2009 – one for each RAC Region.  Each webinar consisted of a panel of experts:  A CMS representative for the Region in question, a RAC representative for the given Region, and Mark E. Reagan, Partner, Hooper Lundy and Bookman Inc.  These webinars provided extremely valuable information on all aspects of the RAC program.  The presentations -- PowerPoint and recordings --  can be accessed at: http://www.ahcancal.org/events/calendar/Pages/Webinars.aspx   They are found under “Archive of Past Webinars.” 

Elise Smith at AHCA:   I can be contacted at 202-898-6305 or esmith@ahca.org

  • CMS Phase-in Strategy -- CMS has implemented a phase in strategy by review type.  CMS has not put a phase in strategy in place by provider type. All provider types are available for RAC review once provider outreach has occurred in the state.   The phase-in-strategy was posted 6/26/2009.  The new updated phase-in-strategy is provided by CMS at http://www.cms.hhs.gov/RAC/Downloads/CMS%20RAC%20review%20strategy.pdf  The color references are to an accompanying map at  RAC Expansion Schedule [pdf, 61.0kb] The dates on the map no longer appear relevant.  We have gleaned the following from these two CMS documents.

Earliest possible dates for reviews in yellow/green states  -- Arizona, California, Colorado, Florida, Hawaii, Indiana, Maine, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, and Wyoming.  

    • Automated Review-Black & White Issues (June 2009)
    • DRG Validation-complex review (Aug/Sept 2009)
    • Complex Review for coding errors (Aug/Sept 2009)
    • DME Medical Necessity Reviews-complex review (Fiscal year 2010)
    • Medical Necessity Reviews-complex review (calendar year 2010)

Earliest possible dates for reviews in blue states --  Washington, Oregon, Idaho, Nebraska, Iowa, Missouri, Wisconsin, Illinois, Ohio, Kansas, Arkansas, Alaska, Louisiana, West Virginia, Tennessee, Mississippi, Alabama, Georgia, New Jersey, North Carolina, Virginia, Kentucky, Pennsylvania, Maryland, Delaware, and Connecticut.

    • Automated Review-Black & White Issues (August 2009)
    • DRG Validation-complex review (Oct/Nov 2009)
    • Complex Review for coding errors (Oct/Nov 2009)
    • DME Medical Necessity Reviews-complex review (Fiscal year 2010)
    • Medical Necessity Reviews-complex review (calendar year 2010)

Note that according to this phase-in strategy, RACs may immediately commence automated review of claims in Arizona, California, Colorado, Florida, Hawaii, Indiana, Maine, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, and Wyoming.  

Automated review will begin by the end of summer in Washington, Oregon, Idaho, Nebraska, Iowa, Missouri, Wisconsin, Illinois, Ohio, Kansas, Arkansas, Alaska, Louisiana, West Virginia, Tennessee, Mississippi, Alabama, Georgia, New Jersey, North Carolina, Virginia, Kentucky, Pennsylvania, Maryland, Delaware, and Connecticut.
The RAC program is expected to be in full swing nationwide by the start of 2010.

  • Issue Posting:  Any reviews completed by the RAC must have been first approved by CMS and posted to the RAC websites. CMS expects the first approved new issues to be posted in July 2009.
  • Critical Issue:  CMS indicates on its website that it is often asked about other claim types that may be affected by a full inpatient denial and if the RACs will deny other claim types associated with the inpatient stay, such as physician evaluation and management services.  CMS states on the RAC web site that “at this time the RAC will not automatically deny claims that are associated with a full inpatient denial. However, these claims may be reviewed individually and there may be a need to fully/partially adjust the claim based on the documentation submitted.”

AHCA is now communicating with CMS on the subject of the impact of a hospital Part A stay denial for medical necessity on a subsequent SNF Part A stay.  We are arguing that the hospital denial should not result in a retroactive denial of the SNF Part A stay. 

Helpful CMS Issuances

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