Editorial
Front Page - Friday, June 19, 2009
Miller & Martin prepares healthcare clients for RAC audits
Samara Litvack
For the past few years, The Center for Medicare and Medicaid Services, or “CMS,” has been conducting a pilot program aimed at identifying and recovering improper Medicare overpayments to healthcare providers. Conducted in a handful of states, the Recovery Audit Contractor program, also called the “RAC program,” recovered $1.03 billion in overpayments from 2005 to 2008.
Earlier this year, CMS announced it would roll out a permanent RAC program in 50 states. Considering results from the test run, it is estimated that approximately $18 billion will be recovered in 2009.
RAC will affect all Medicare providers and suppliers, including everything from hospitals to medical equipment companies. Auditors will collect data from a small, core sample and if errors are detected, the numbers will be extrapolated over all the billing an institution has made in the past three years, and repayment will be made accordingly.
To prepare for this national effort, Miller & Martin PLLC’s Healthcare Practice Group has formed a specialized RAC legal appeals team. To ensure its healthcare clients are well versed in the process’s appellate process, the group held seminars earlier this week for clients in the Chattanooga and Nashville areas.
Miller & Martin attorneys Christie Burbank, of Chattanooga, and Bryant Witt, of Nashville, are co-chairing the firm’s RAC team, which also includes attorneys Kenneth Bryant and Christopher Vas, of Nashville, and Richard Rose, of Chattanooga.
“There are technical errors that can happen that can cause an over-recovery that doesn’t truly reflect what should have been done in the first place,” said Witt. “It’s absolutely important that coding be as accurate as it can be and I think every healthcare provider is aware of that and striving for that excellence.”
The country has been divided into quadrants, each of which will be audited by a separate contracted organization. RACs will begin work in the Southeast beginning August 1, 2009.
“The one thing to realize is that CMS has always had a program whereby they could come in and audit Medicare billing,” says Witt. “The difference is the way this is so much more widespread, so much more organized and, most importantly, the way it’s incentivized.”
Auditors will keep one-third of what they recover in the RAC process, and Witt says that is keeping many healthcare clients on the edge of their seats.
“It’s not as if you’re going to find these overbillings and you’re going to get to go through years and years of appeals before you ever have to pay it back. The way Medicare payments are made, the government can potentially just hold back what they would normally be paying you,” he says.
“In other words, if this RAC decides you have overbilled a certain amount, the government can hold back the next Medicare payment until it evens out.”
Adds Burbank: “It will be very costly to healthcare providers for many reasons, not only paying back, if that’s the result, but also trying to defend or appeal any of these adverse decisions.”
That’s where Miller & Martin’s RAC team comes in. Its goal to educate clients on the front end and become involved in the process as soon as possible is a proactive approach, taken in the best interest of its healthcare clients.
“The reason they need to get us involved early on is because, through experience thus far, early appeals were more successful than any of the later appeals,” says Burbank.
At Miller & Martin’s recent seminars, the RAC team explained the complete RAC process. It emphasized the importance of self-audits and went over the five levels of appeal in detail:
Redetermination: These appeals are made to the Medicare Fiscal Intermediary or the carrier that initially processed the claim. They have no monetary limit, but must be made within 120 days after receipt of the RAC contractor’s determination. The Medicare Fiscal Intermediary has 60 days from the date of receipt to issue a redetermination decision.
Reconsiderations: These appeals are made to a CMS-appointed qualified independent contractor and must be made within 180 days of the receipt of the Medicare Fiscal Intermediary’s redetermination. There is no monetary limit to this appeal, but it is crucial at this level to make certain that the record is complete because additional evidence in support of the claim may not be admitted at later appellate stages. The contractor has 60 days from the date of the reconsideration request to issue a decision.
Administrative Law Judge: This appeal is pursued if the controversy exceeds $120. Request for such a hearing must be filed within 60 days after receipt of the previous reconsideration decision and may be conducted either in person, by phone or by video conference. A ruling is due within 90 days from the date the Office of Medicare Hearings and Appeals receives the hearing request. The decision is binding unless it is revised by either the administrative law judge, a federal district court or the Medicare Appeals Council.
Medicare Appeals Court: This appeal takes place within the Department Appeals Board of the U.S. Department of Health and Human Services. The review must be filed within 60 days of an administrative law judge’s decision, and the Medicare Appeals Council
must issue a decision within 90 days of the review request.
United States District Court: If a provider disputes the decision handed down by the Medicare Appeals Court, it may be appealed on this final level. The amount in controversy must be at least $1,220, and the request must be filed within 60 days of the Medicare Appeals Court decision.
“Not all government guidelines regarding seeking reimbursement by providers are clear. There’s a whole lot of ambiguity out there,” said Burbank.
“Coding has got a very large subjective element,” said Witt. “The provider and the RAC may not agree on how a particular diagnosis or treatment should have been characterized. And so a lot of what we do as healthcare attorneys is we present to the financial intermediary and then to the ALJ if necessary. We create a record on appeal showing why our client provider did things correctly in the first place.”
|
|