The Recovery Audit Contractor (RAC) initiative is a Centers for Medicare and Medicaid Services (CMS) initiative that began in 2005 as a demonstration project in three states including California. A permanent RAC program is begins in mid 2008.
Under the RAC program, private companies are contracted to retrospectively review Medicare claims for potential over-payments or under- payments.
CHA President/CEO C. Duane Dauner was joined by 10 representatives of CHA member hospitals in Washington, D.C., Dec. 3 for the CHA and American Hospital Association hospital advocacy day. The group met with about half of the California Congressional delegation, including House Minority Leader Nancy Pelosi, House Majority Whip Kevin McCarthy, and Sens. Boxer and Feinstein.
The Centers for Medicare & Medicaid Services (CMS) will hold its third special open door forum (ODF) regarding the new inpatient admission and medical review criteria commonly referred to as the two-midnight rule Tuesday, Nov. 12 from 10 a.m. – 11 a.m. (PT). This call will give hospitals an important opportunity to ask CMS questions about the finalized policy and recently released subregulatory guidance from Nov. 5. To participate, call (866) 501-5502 and enter Conference ID # 98515298.
CHA urges Critical Access Hospitals to also participate in CMS’ special ODF on Wednesday, Nov. 13 from 11 a.m. – noon (PT). Special attention will be paid to clarifying the condition of payment related to the 96-hour rule as well as the related condition of participation. To participate, call (800) 837-1935 and use conference ID # 70964241.
The Centers for Medicare & Medicaid Services (CMS) has posted the attached transcript from its Sept. 26 special open door forum (ODF) regarding the new inpatient admission and medical review criteria commonly referred to as the two-midnight rule. On the call, CMS read frequently asked questions and attempted to clarify a number of questions unaddressed in recent guidance, including the 96-hour rule for critical access hospitals (CAH). CMS has announced a rural health ODF for Wednesday, Nov. 13 from 11 a.m. – noon (PT) that will further clarify guidance on the CAH 96-hour rule. The ODF agenda also includes discussion on rural health clinic contracting policies proposed in the federally qualified health center prospective payment system proposed rule. To participate, dial (800) 837-1935 and reference conference ID 70964241.
The Centers for Medicare & Medicaid Services (CMS) has released additional guidance regarding the two-midnight inpatient hospital medical review and admission criteria. CMS indicates that it will not conduct post-payment patient status reviews for claims with dates of admission Oct. 1, 2013, through March 31, 2014, three months longer than previously announced. In addition, CMS posted the attached documents setting forth more details on the “probe and educate” audits that will be conducted by Medicare Administrative Contractors. However, the guidance leaves a number of questions unaddressed, and certain areas appear to be inconsistent with guidance previously issued by the agency. For example, the new guidance states that critical access hospitals (CAHs) will be included in the probe audits, although previous guidance specifically excluded CAHs from the audits. CHA will continue to seek clarity from both CMS and Noridian and will provide members with additional information as it becomes available. For additional resources on the policy, visit www.calhospital.org/resource/inpatient-admission-and-medical-review-resources.
The American Hospital Association (AHA) has extended the deadline for hospitals to complete its RACTrac survey to Friday, Oct. 18. In an effort to enhance advocacy efforts in the coming months, CHA encourages members to participate in the survey if they haven’t already. RACTrac data will be used to analyze the impact of the Medicare Recovery Audit Contractor (RAC) program on hospitals and will help guide CHA’s advocacy for congressional action on legislation that, if enacted, would make important and necessary changes to the RAC program. Non-AHA members may participate in RACTrac. For registration information, contact AHA’s RACTrac Support at (888) 722-8712 or firstname.lastname@example.org.
In an effort to enhance advocacy efforts in the coming months, CHA reminds members to complete the American Hospital Association’s (AHA) RACTrac survey by the deadline of Friday, Oct. 19. RACTrac data will be used to analyze the impact of the Medicare Recovery Audit Contractor (RAC) program on hospitals and will help guide CHA’s advocacy for congressional action on legislation that, if enacted, would make important and necessary changes in the RAC program. AHA membership is not a requirement to participate in RACTrac; CHA encourages all hospitals to participate regardless of AHA membership status. For registration information, contact AHA’s RACTrac support at (888) 722-8712 or email@example.com.
The Centers for Medicare & Medicaid Services (CMS) today released additional information regarding the “two-midnight” benchmark and presumption for inpatient admission and medical review criteria. During its hospital open door forum, CMS announced that it will not allow post-payment review of patient status by the MACs or the RACs on inpatient claims that span two midnights for admissions beginning on or after Oct. 1 through Dec. 31, 2013. Further, it will not permit RACs to review inpatient admissions of one midnight or less that begin on or after Oct. 1, 2013. When asked if CMS would prohibit review of these claims at a later date, CMS staff confirmed that it is not their intention to have these claims reviewed at a later date.
The Centers for Medicare & Medicaid Services (CMS) will host its second in a series of calls intended to educate hospitals about the two-midnight benchmark for inpatient admissions on Thursday, Sept. 26 from 11 a.m. to noon (PT). The call also will include the physician order and physician certification, inpatient hospital admission and medical review criteria included in the federal fiscal year 2014 inpatient prospective payment system (IPPS) final rule. Providers will have an opportunity during the call to ask CMS questions about the policies. CHA encourages members to participate in this important call. To participate, dial (866) 501-5502 and enter conference ID 68257949. Providers can also provide feedback to CMS on the two-midnight provision by sending an email to IPPSAdmissions@cms.hhs.gov. Additional resources on the policies are available on CHA’s website at www.calhospital.org/resource/inpatient-admission-and-medical-review-resources.
**Please note the dial-in number was changed by CMS shortly before the call. The dial-in number above reflects the updated version.
Last month the California Department of Health Care Services (DHCS) announced that Health Management Systems (HMS) was awarded the state’s Medi-Cal Recovery Audit Contract. On Friday, CHA met with DHCS and HMS to discuss the current scope of work. HMS will begin its first round of reviews by auditing the following provider types: transportation services, speech therapy, podiatry and optometry. DHCS and HMS advised that hospitals are not included in the initial scope of review. However, they anticipate the scope will be expanded by the end of 2014 to include hospitals. CHA will continue to communicate directly with HMS and advise hospitals as the scope of work changes.
The Office of Inspector General (OIG) has released a report regarding Medicare Recovery Audit Contractors (RAC) and the Centers for Medicare & Medicaid Services’ (CMS) inaction in addressing improper payments, referrals of potential fraud and performance. The OIG report identified vulnerabilities in CMS’ oversight of its RACs; specifically, the report found CMS’ performance evaluations did not include metrics to evaluate RACs’ performance on all contract requirements. The report also found that in 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments, totaling $1.3 billion. CMS took corrective actions to address the majority of vulnerabilities it identified in 2010 and 2011. However, it did not evaluate the effectiveness of these actions. Therefore, the OIG report predicts a high volume of improper payments may continue.
According to results from the American Hospital Association’s quarterly RACTrac survey, recovery audit contractor (RAC) reviews continue to increase for hospitals. AHA reports that medical record requests have increased by 47 percent, while complex audit denials have increased by 58 percent since the fourth quarter of 2012. In addition, 45 percent of hospitals that participated in the survey experienced overturned denials through use of the discussion period.
AHA will host a webinar on Sept. 19 to review the RACTrac survey results as well as recent Centers for Medicare & Medicaid Services regulations that impact the RAC program. For more information, visit www.aha.org/ractrac. A copy of the survey report is attached.
The Centers for Medicare & Medicaid Services (CMS) has posted a transcript and recording of the national provider call held on Aug. 15 regarding newly revised policies implemented in the federal fiscal year 2014 inpatient prospective payment system final rule. The call focused on policies related to the physician order certification for inpatient hospital admission, as well as the medical review criteria that will be used by the MACs and RACs in reviewing inpatient admissions. CMS also reviewed the final rule’s Part B inpatient billing provisions. CMS is still seeking feedback from providers as it develops guidance for the MAC and RAC auditors, and CHA urges members to submit questions and comments to IPPSAdmissions@cms.hhs.gov. The transcript and link to the audio recording are attached.
The American Hospital Association will host a webinar Sept. 19 at 11 a.m. (PT) to review the results of its most recent RACTrac survey, including data on delays during the appeals process. The webinar also will emphasize recent regulatory activity related to the recovery audit contractor (RAC) program. AHA’s RACTrac survey measures the impact of Medicare RACs and helps CHA develop advocacy strategies for improving the program. For more information about RACTrac, visit www.aha.org/ractrac.