RAC Requests: Dig Back for that Info and Send It Along

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BALTIMORE — CMS representatives assured listeners on a
“RAC 101” conference call May 5 that the recovery audit
contractors’ post-pay reviews would be limited by a rolling “look
back” period of three years. Specifically, auditors would not look
back beyond Oct. 1, 2007, in an effort to “minimize provider burden
… We understand we are asking for a lot of information from
providers,” officials said.

The RACs, which are paid a contingency fee based on the amount
of improper payments they ferret out and collect, will also limit
the number of additional documentation requests. While these
documentation limits have not yet been established for DME, Scott
Wakefield, CMS’ RAC project officer for RAC Regions A and B,
anticipated the agency would likely set those boundaries as early
as June.

“If the provider is simply overburdened by the number of medical
records requested by the RAC at any time, they should contact the
RAC immediately because the RACs are authorized by CMS to grant
extensions … to help alleviate the provider burden,”
Wakefield said.

Even so, presenters on the call counseled HME companies to be
prepared to respond to additional documentation requests by giving
the RAC “the precise address and contact person” they should use
when sending out ADR letters.

On the always-contentious topic of documentation, two
questioners during a Q&A session on the call took the
opportunity to ask about the nuances and difficulties of providing
the correct information to auditors.

Here’s one exchange:

Caller: In reference to the
look-back period, is this based on the initial setup of the
equipment or an individual rental episode?

CMS: It is the claims paid date,
if that helps at all.

Caller: That helps, but just keep
in mind that in the durable medical equipment world, with renting
equipment we could have an oxygen patient who could have been set
up for seven or eight years. If the RAC is going back and asking
for physician progress notes or information from the physician’s
records, it is very challenging to obtain that information because
they don’t keep it on file. We might have the appropriate
certificate of medical necessity, but if they are looking for
additional information that should be in the physician’s records,
it is often challenging to produce if you are going back …
and basing it off of a rental episode versus the initial setup of
the equipment.

CMS: You raise a good point, but
in fact if you receive an additional documentation request letter,
you will see a list of items that you should provide. Essentially
providers will want to give any documentation that they feel would
substantiate the valid payment of a claim, including … any
records before the actual claims paid date. So that is kind of up
to the providers. CMS is not prescriptive to the RACs on what
exactly they would require, but if you feel that it would help
substantiate payment of a DME claim, then I would suggest digging
back and finding that information.

And on the topic of extrapolation:

Caller: Is extrapolation part of
the RAC process?

CMS: Extrapolation on the part of
the RAC is permissible … but I think that it is important to
note that during the three-year demonstration, none of the RACs did
that. And if they decide to use the extrapolation process going
forward in the national program, they need to follow all CMS policy
and guidance on extrapolation — including using stratified
random sampling. The easy answer to that question is “yes,” they
can perform extrapolation.

The 90-minute “RAC 101” phone call outlined several points from
a slide presentation available on the CMS RAC website.

New issues are posted to each of the RAC region websites:

On the possibility of double or triple audits, Wakefield said,
“it is our hope” that other Medicare reviewing entities would use
the RAC data warehouse so providers don’t get asked a second time
for the same medical record.

“If I were a provider, I would submit as much or any
documentation that you felt would be relevant or pertinent to
substantiate a claim,” Wakefield said. “It might be hard to get
from a physician, but that’s not something the RACs can determine
or direct.”

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