A collective sigh of relief was heard across the land as it was revealed today during the CMS Open Door Forum that the requirement for providers to be enrolled in PECOS has been delayed until January 3, 2011.

Part B MACs (Medicare Administrative Contractors) will be sending revalidation letters to all providers who have not updated their Medicare enrollment since November of 2003, asking them to submit a paper enrollment form or to use the electronic enrollment system PECOS (Provider Enrollment, Chain and Ownership System.) This proactive stance on the part of CMS should help the many managers who have been desperately trying to determine if their providers are in PECOS or not.

An audio recording of today’s call will be available on the ODF website here and will be accessible for downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions click here.

On February 17, 2010 from 2:00PM – 3:30PM ET the Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss Medicare provider enrollment issues. During this call, CMS staff will discuss:

• Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for physicians, non-physician practitioners and provider and supplier organizations
• Provider and supplier reporting responsibilities
• Medicare ordering and referring issues
• Revalidation efforts

Afterwards, there will be an opportunity for the public to ask questions.

Open Door Forum Instructions:

**Capacity is limited so dial in early. You may begin dialing into this forum as early as 1:45 PM ET.**

Dial: 1-800-837-1935
Reference Conference ID 52537484
An audio recording of this Special Forum will be posted to the Special ODF website here and will be accessible for
downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to
view Frequently Asked Questions click here.

As of April 5, 2010, if the ordering/referring provider of goods and services on the CMS-1500 claim is not listed in PECOS and eligible to order/refer, the claim will not be paid.  Your patients may not be able to get the items they need, they may have problems with rented items (going three years back) and hospital discharges may be delayed.  Even if your practice doesn’t fall into any of these categories, you will fall into some Medicare category sooner or later, particularly if you need to inform CMS of any practice changes.

If your providers aren’t in the PECOS database, you should bite the bullet and GET STARTED TODAY!

Some terminology I use in this article:

AO = Authorized Official

CMS = Centers for Medicare & Medicaid Services

EUS – External User Services (for CMS PECOS) Help Desk

MAC = Medicare Administrative Contractor

NPPES = National Plan and Provider Enumeration System (the system that assigns the National Provider Identifier (NPI)

Providers = physicians and non-physician practitioners (I know physicians hate being called “providers”, but there it is.)

Type I NPI = National Provider Identifier for a physician or non-physician practitioner

Type II NPI = National Provider Identifier for a practice or organization

WHAT is PECOS?

PECOS stands for the Provider Enrollment and Chain/Ownership System. It was created by CMS as an electronic portal for Medicare enrollment of physicians, non-physician practitioners, and provider and supplier organizations.

Even though some providers are enrolled in Medicare, their enrollment records might not be in PECOS. If they have not sent in a Medicare application to report any changes to their Medicare enrollment information within the past 5 years, they probably do not have an enrollment record in PECOS. These individuals will need to submit a  Medicare enrollment application. To see if a provider is enrolled in PECOS, check here. If the name is not there, the PECOS enrollment is incomplete or missing.

PECOS is designed to electronically:

• Enroll in the Medicare program
• Make changes to Medicare enrollment information
• View existing Medicare enrollment information
• Withdraw from the Medicare program
• Check the status of an Internet-submitted Medicare enrollment application

While PECOS supports most enrollment application actions, there are some limitations. Providers cannot use PECOS to:

• Change his/her name or Social Security Number, or changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855)
• Change an existing business structure or changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). An example of a change to a business structure is:
  • A sole owner of an enrolled Professional Association, Professional Corporation, or Limited Liability Company cannot change the business structure to a sole proprietorship; or
  • An enrolled sole proprietorship cannot be changed to a solely-owned Professional Association, Professional Corporation, or Limited Liability Company.
• Reassign benefits to another supplier if that supplier does not have a current Medicare enrollment record in PECOS.
• An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B Medicare Administrative Contractor (MAC) to bill for Part B services. This must be done using the paper enrollment application (CMS-855).

WHY should I use PECOS?

Described as being 50% faster than paper, PECOS will alert the applicant when a response is inadequate or unacceptable, thereby decreasing the possibility of a rejected application.

Going forward, Medicare providers are required to notify Medicare of reportable events within a specific timeframe or risk losing their ability to bill for services provided to Medicare patients. A reportable event is any change that affects information in a Medicare enrollment record. A reportable event may affect claims processing, claims payment, or a provider’s eligibility to participate in the Medicare program.

Effective April 4, 2010, providers are required to report the following changes within 30 days of the following reportable events:

• Change in ownership
• Change in practice location, and
• Final adverse action.

A final adverse action includes: (1) a Medicare imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

Providers are required to report the following changes immediately, but not later than 90 days, after the reportable event:

• Change in practice status (e.g., retirement, voluntary surrender of medical license or voluntary withdrawal from the Medicare program)
• Change of business structure, Legal Business Name or Taxpayer Identification Number
• Banking arrangements or payment information
• A change in the correspondence or special payments address

Hopefully, PECOS should make this reporting easier by:

• Reducing the time necessary for provider and supplier organizations to enroll or make a change in their Medicare enrollment information;
• Streamlining the Medicare enrollment process for provider and supplier organizations;
• Allowing provider and supplier organizations to view their Medicare enrollment information to ensure that it is accurate; and
• Reducing the administrative burden associated with completing and submitting enrollment information to Medicare.

So far the above has not been the case, but let’s move on.

WHO needs to enroll in PECOS?

• If you are not enrolled in the Medicare program and want to become enrolled,  you do.
• If you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do. If a provider who is currently enrolled in the Medicare program has not submitted a complete Medicare enrollment application (CMS-855) since November 2003, the Medicare contractor will require the individual or organization to submit a complete CMS-855 in order to update or make a change in their enrollment information.

In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application, which you may do in one of two ways:

1. Using Internet-based PECOS (which transmits your enrollment application to the MAC) AND BE SURE to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application.
2. Filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R , if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site here.

If you are already enrolled in Medicare, make sure you have a current enrollment record in PECOS.  You can find out by:

• Calling your designated carrier or A/B MAC (recommended). Find out who your A/B MAC is here.
• Using PECOS to view your enrollment record.
• Going to Medicare.gov and searching for the provider

If you are a dentist or a physician with a specialty such as a pediatricians who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

WHICH paper enrollment form should be used?

CMS uses five different provider and supplier enrollment applications:

• Part A providers are required to use the CMS-855A to enroll or update their enrollment information;
• Part B suppliers (except suppliers of Durable Medical Equipment, and Prosthetics, Orthotics, and Supplies (DMEPOS)) are required to use the CMS-855B to enroll or update their enrollment information;
• Physicians and non-physician practitioners are required to use the CMS-855I to enroll or change their enrollment information;
• DMEPOS suppliers are required to use the CMS-855S to enroll or update their enrollment information.
• Individual practitioners who would like to reassign their benefits to an eligible provider or supplier or terminate an existing reassignment agreement would use the CMS-855R.

You should file a CMS-855A (pdf) with the designated MAC if you would like to enroll your organization in the Medicare program as one of the following types of providers.

• Community Mental Health Center
• Comprehensive Outpatient Rehabilitation Facility
• End-Stage Renal Disease Facility
• Federally Qualified Health Center
• Histocompatibility Laboratory
• Home Health Agency
• Hospital
• Hospice
• Indian Health Services Facility
• Organ Procurement Organization
• Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services
• Religious Non-Medical Health Care Institution
• Rural Health Clinic
• Skilled Nursing Facility

You should file a CMS-855B (pdf) with the designated MAC if you would like to enroll in the Medicare program as one of the following types of suppliers:

• Ambulance Service Supplier
• Ambulatory Surgical Center (site visit or state survey typically required)
• Clinic and Group Practices
• Hospital Departments
• Multi-Specialty Clinic
• Public Health/Welfare Agency
• Physical/Occupational Therapy Group in Private Practice
• Single Specialty
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (site visit or state survey typically required)
• Mammography Center
• Mass Immunization – roster biller only
• Portable X-ray Facility (site visit or state survey typically required)
• Radiation Therapy Center
• Slide Preparation Facility
• Voluntary Healthy/Charitable Agency

You should file a CMS-855I (pdf) with the designated MAC  if you would like to enroll in the Medicare program as one of the following types of providers.

• Physicians (all specialties)
• Non-Physicians
  • Anesthesiology Assistant
  • Audiologist
  • Certified Nurse Midwife
  • Certified Nurse Specialist
  • Certified Register Nurse Anesthetist
  • Clinical Social Worker
  • Mass immunization, roster biller (individual only)
  • Nurse Practitioner
  • Occupational Therapist in private practice
  • Physical Therapist in private practice
  • Physician Assistant
  • Psychologist, Clinical
  • Psychologist, billing independently
  • Registered Dietitian or Nutrition Professional

NOTE!! If you are enrolled in Medicare and your NPPES record is correct, you are not re-enrolling, you are revalidating, an important distinction in terminology. The word on the street is that it seems to be easier to revalidate via paper by completing the CMS-855 and writing “REVALIDATION” in the upper margin of the first page.

WHAT information is needed for a PECOS enrollment?

Below is a list of the types of information needed to complete an initial enrollment action using PECOS. This information is similar to the information needed to complete a paper Medicare enrollment application. You may find it useful to print and review the CMS-855 paper enrollment application before initiating an Internet-based PECOS enrollment action.

• An active National Provider Identifier (NPI).
• The NPI of the Practice (PA, PC, or LLC)
• National Plan and Provider Enumeration System (NPPES) User ID and password.
• Personal identifying information. This includes legal name on file with the Social Security Administration, date of birth, Social Security Number
• Professional license and certification information. This includes information regarding the physician’s or non-physician practitioner’s professional license, professional school degrees or certificates.
• Practice location information. This information includes information regarding the practitioner’s medical practice location, the legal business name of a solely-owned Professional Association, Professional Corporation, or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575
• Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
• A photocopy of the CP-575 form;
• If applicable, information regarding any final adverse actions. A final adverse action includes: (1) a Medicare-imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.

The following forms are routinely submitted with an enrollment application:

• Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS 588)
• Medicare Participating Physician or Supplier Agreement (Form CMS 460)

HOW do you enroll in PECOS?

There are three basic steps to completing an enrollment action using Internet-based PECOS. Providers must:

1. Have an active National Provider Identifier (NPI) and have a web user account (User ID/Password) established.  For security reasons, providers should change passwords periodically, at least once a year. If you/your provider needs help in changing your password, contact the NPI Enumerator at 1-800-465-3203 or send an email to customerservice@npienumerator.com.
2. Go to Internet-based PECOS by clicking on this link and complete, review, and submit the electronic enrollment application via Internet-based PECOS.
3. Print, sign and date the 2-page Certification Statement for each enrollment application submitted and mail the Certification Statement and all supporting paper documentation to the Medicare contractor within 7 days of electronic submission. Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed Certification Statement that is associated with the Internet submission. The Certification Statement must be signed by the provider enrolling or making changes to enrollment information. Signatures must be original and in ink (blue ink recommended). Copied or stamped signatures will not be accepted.  NOTE: CMS encourages providers to print and retain a copy of the enrollment application for their records, however providers should only mail the 2-page Certification Statement and supporting documentation to the designated Medicare contractor.

HOW can managers facilitate the enrollment?

• Look at your original Medicare application to see who is the “authorized official”. The Authorized Official (AO) may be theprovider, or may be the owner of the practice, or the CFO of the hospital, in the case of a hospital-owned practice.  The AO (in an original application) may be registered through PECOS and an approval email will be issued in 3-4 weeks. Print the screen that provides the tracking ID.  You will need to refer to it in the future.
• If you do not have a copy of your organization’s original Medicare enrollment information and do not know who has been designated as your organization’s “authorized official”, an owner of your practice must submit a written letter on the organization’s letterhead to your Medicare contractor authorizing the release of that information.  Medicare contractors are not allowed to release such information over the telephone or in an e-mail, and neither are they allowed to release it to practice staff.
• The organization AO goes into PECOS Identification & Authentication (I & A) and registers. As part of this process, the AO must mail a photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can verify the organization provider/supplier. Print the screen that provides the tracking ID.  You will need to refer to it in the future.
• The Help Desk verifies both the organization provider/supplier and the AO, and approves the AO’s registration. The AO receives a system-generated e-mail indicating that the registration has been approved.
• Once the AO receives this notification, the AO can let the end-user know that he/she can register in PECOS.
• The end-user goes into PECOS I&A and registers. The registration request will be directed to the AO of the provider/supplier organization.
• The AO must approve or reject the end-user in PECOS I&A.
• Once the end-user has been approved in PECOS I&A by the AO for access on behalf of the organization provider/supplier, the end-user will receive a system-generated e-mail indicating that he/she has been approved.
• The end-user then logs into PECOS and downloads the Security Consent Form. He or she fills it out, obtains the signature/date of signature of the AO, and mails the completed Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San Antonio, TX 78216.
• The Help Desk verifies the information on the Security Consent Form and also calls the AO to verify that the AO did, in fact, sign the Security Consent Form.
• Once the information on the security Consent Form has been confirmed, the Help Desk approves the Security Consent Form in PECOS and an e-mail is sent to the AO notifying the AO that the end user’s organization has been approved to use Internet-based PECOS on behalf of the organization provider/supplier.
• It is the AO’s responsibility to notify the end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because the AO is ultimately responsible for the enrollment information and who has access to that enrollment information. It is the AO’s responsibility to inform the end-user that the Security Consent Form has been approved.

TO RECAP:

• Providers, if you search for yourself at Medicare.gov and cannot find your record, you do not have a PECOS record – it is either missing or incomplete.  Call Provider Enrollment at Medicare or your MAC for help.
• If you do not have a PECOS record, send in a paper enrollment or complete the online (PECOS) enrollment.
• The prerequisite for getting a PECOS record is to have a NPPES record.  Make sure you have your NPPES login and password and that your record (Type I NPI) is correct.  Your organization also needs an NPPES record (Type II NPI), and make sure your organization name on the NPPES record matches the name on your IRS letter.

RESOURCES

Read about PECOS in downloadable documents section: Downloads for PECOS

The AMA and MGMA have published an absolutely excellent resource:  “The Medicare Provider Enrollment Toolkit” available here for MGMA members. Enter “Medicare Enrollment” in the search box.

The CMS External User Services (EUS) Help Desk contact information for providers and suppliers using PECOS can be found here (pdf) on the CMS website. The Help Desk hours of operation are Monday – Friday, from 6 a.m. to 6 p.m. Central Standard Time. The Help Desk toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com. Questions about accessing and using PECOS should be directed to the CMS EUS Help Desk, although I have heard lots of complaints about long wait times and conflicting advice.

The Medicare Learning Network has a listserv that will keep you updated on all the CMS news here.

Readers: Please share any clarifying information or tips from your enrollment experiences with everyone.  Leave a comment and share the wealth!

For those of you who have not tapped into the amazing wealth of information generously shared by Frank Cohen, go to his site now and see what he has that could help you.

Most recently Frank analyzed the October 2009 NCCI Edits Release 15.3 and organized the information into meaningful categories as well as providing an executive summary.

As a reminder, the CMS website tells us:

The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.

Per Frank’s assessment of the 2009 changes effective on October 1:

There are 706 terminated edit pairs but once again, around half have been terminated retrospectively. Two are terminated back to last quarter (7.1.09), 357 back to April, 2009 and 27 all the way back to January, 2009. This means that, if you were denied payment on edit pairs that are part of this last over the past few quarters, you should be able to resubmit and get paid. The big hitters for terminated codes in both column 1 and column 2 fell within the surgical code category (520 and 513, respectively).

For more information, go to Frank’s site here, go to the Download tab and you will see the link at the top of the page.

Today I was fortunate enough to attend an outreach session designed to educate hospitals, physicians and other providers about Recovery Audit Contractors (RAC), specifically Connolly Consulting, the RAC for North Carolina.  Although I cannot vouch that the information I am sharing for Region C will be consistent for the other three RACs, the fact that there is a standard handout being used for all RAC outreach sessions makes me think there’s a very good chance that CMS is encouraging a high level of consistency.

If you read the recent Manage My Practice article here by Carla Hannibal, you already know that the RACs were established after CMS demonstration projects proved “to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments.” (CMS website)

Each RAC bid for and won the jurisdiction as follows:

• Region A: CT, DE, DC, MD, ME, MA, NH, NJ, NY, PA, RI, VT Diversified Collection Services (DCS) -1-866-201-0580, website here
  

• Region B: MN, WI, IL, IN, OH, MI, KY CGI Technologies and Solutions -1-877-316-7222, website here

• Region C: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands. Connolly Consulting, Inc. -1-866-360-2507, website here

• Region D: WA, OR, ID, CA, NV, MT, WY, UT, AZ, ND, SD, NE, KS, IA, MO, AK, HI HealthDataInsights, Inc.-Part A: 866-590-5598, Part B: 866-376-2319, e-mail: website here

Each RAC is required to provide outreach education sessions in their region prior to sending out any letters.   Any hospital or physician who bills fee-for-service programs (Part A and/or Part B) for Medicare beneficiaries is eligible for a RAC audit.

These are the important points that I took away from attending this outreach program:

1. RACs may review claims as far back as October 1, 2007.
2. RACs review claims after they have been paid using the same Medicare policies used to pay the claim initially.
3. There are two types of reviews: Automated Reviews which do not request the medical record and Complex Reviews which will request the medical record.
4. Automated Reviews are “done deals” and the claim will be adjudicated and a letter sent detailing the dollars requested.
5. Providers may return the payment by writing a check, allowing a recoupment from future payments or may apply for an extended payment plan.
6. Complex Reviews entail a request for medical records.  Records can be mailed, faxed, or sent on a CD/DVD.  Mailed records must be sent in a tamper-proof package, and should be sent via trackable carriers (FedEx, UPS, Registered USPS.)  Multiple records may be sent in one package if each record set is in a separate envelope inside the package.
7. Note: if faxing, fax the records to yourself to check for readability before you fax to the RAC.
8. Email records are currently not acceptable due to HIPAA.
9. Providers have 45 days plus 10 mailing days for a total of 55 days to send the records, but extensions are available if this is not abused.  If you do not communicate with your RAC about any problems you are having sending the records (e.g. you can’t find the record!), you risk having the claim(s) automatically recouped.  The Connolly representative even mentioned something to the effect that she wasn’t above calling the practice/entity CEO to let them know that their contact person wasn’t playing by the rules.
10. Once a claim has been reviewed and a Complex Review is in play, the provider will receive a Demand Letter from the RAC and the provider will have a “discussion period” to contact the RAC and ask questions and/or provide additional information.  The RAC representative emphasized to communicate, communicate, communicate and to call the RAC and  speak to the reviewer of the claim.  Once you have spoken to the reviewer, if you still disagree with the decision, you should ask to speak to the supervisor, and if there still is no agreement, you need to file an appeal.
11. Appeals must be filed within 120 days of the receipt of the demand letter from the RAC.
12. To fully understand the appeals process, go to the appeals flowchart here (this is a pdf.)

Here is a suggested action plan for physician practices to prepare for the RAC process:

1. Visit the CMS website here and click on Demonstration Projects to see what improper payments were found by the RAC demonstration projects.
2. Visit the CMS and OIG websites to see what improper payments were found by reading the OIG (Office of Inspector General) reports here and CERT (Comprehensive Error Rate Testing) reports here.
3. Conduct an internal assessment to see if you are in compliance with Medicare rules, and if not, identify corrective actions needed to bring your group into compliance.  Corrective actions may include provider education and a periodic internal audit to rate the improvement.
4. Provide your RAC (they will tell you how to do this) with a contact person who will receive RAC letters and who will be the point person for providing the RAC with additional documentation.  The RAC will also ask for information about providers and their NPIs, including any providers who were with the group between October 1, 2007 and now, even if the provider is no longer with you.  Connolly suggests copying the list of providers you supply to the RAC and placing it in the personnel file of the contact person to be reminded of this important responsibility if this person leaves the organization.
5. Develop a basic tracking system for receipt of letters, and activity for each request.
6. VISIT YOUR RAC WEBSITE AT LEAST WEEKLY.

I have received lots of questions about what a RAC letter will look like, and the speaker today provided a sliver of information saying that the Region C letters will have the CMS logo at the top of the letter and Connolly’s logo at the bottom of the letter.  Because your practice/entity will be providing the RAC with a contact person’s name, unless things are in total chaos at your place of business, the letters will go to the person you’ve entrusted with this important responsibility.

Here are some other questions and answers from the program today:

Q: Does the RAC pay for the copying/mailing for records?

A: They will pay hospitals, but will not pay physicians for record expense.

Q: If  a claim is refunded to Medicare, must the patient be refunded their portion?

A: Yes.

Q:What determines which region the practice/entity belongs to for RAC?

A: The state that the practice/entity is located in.

Q: Are patients contacted if their claim is audited?

A: They receive a notice if the claim is adjusted in any way.

Q: I heard that there are consultants selling RAC insurance – is that a good idea?

A: There is no such thing as audit insurance, but there is such a thing as appeal insurance.

Q: Will a claim be audited if a practice/entity self-audits, finds an error and corrects it?

A: As long as an amended claim is filed by the provider, RAC will not audit the claim.

Q:Who sets the guidelines for medical necessity?

A: The medical director of the RAC.

Q: Are the number of claims that can be audited in each period counted by transaction lines (5 per CMS form) or by claim/single CMS form?

A: By transaction lines.

Q: Will the RACs extrapolate their findings?

A: The RACs are entitled to extrapolate their findings if they so choose.

Q: Are the RACs paid on a percentage of their findings?

A: Yes, RACs are paid a percentage of both overpayments and underpayments.  The percentage ranges from 9% to 12.50% based on each RAC’s bid.

If this information is new to you, I suggest you click on some of the links provided in this article, start developing your RAC plan, and start educating your providers and staff.  This topic is also a good one for sharing of best practices between local and regional groups.  To get email updates on RAC from CMS, sign-up here. Remember to bookmark your RAC’s website and visit often!

Photo credit: © Milosluz | Dreamstime.com

The Medical Home, also called the Patient-Centered Medical Home, and the Personal Medical Home, is a movement to solve the problem of fragmented care (one hand doesn’t know what the other is doing) by having a primary care physician or practitioner act as the center of all care information for the patient.   Fragmented care is dangerous (lack of coordination of care causes mistakes and mistreatments), costly (repetition of diagnostic tests and regimens), and wasteful of healthcare resources.  The Medical Home plan goals are to provide care for all individuals, improve care, and decrease healthcare costs.

“Crossing the Quality Chasm: A New Health System for the 21st Century” was published in 2001 by the Institute of Medicine.  In this landmark book, the patient’s role and responsibility for navigating the healthcare system and acting as the information hub around which the spokes of primary, specialty and tertiary care providers revolve was denounced (more…)

By Carla Hannibal, CMM,CPM,CIMBS

Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act.  Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond.  RACs will audit every United States and Peurto Rico health care provider who files with Medicare.  The audit and recovery plan is expected to be in place by (more…)