2010 Mid-Winter Conference highlights.
Article Type: Report
Subject: Medicare (Laws, regulations and rules)
Medicine (Practice)
Medicine (Planning)
Author: Good, Barbara
Pub Date: 03/01/2010
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: March-April, 2010 Source Volume: 106 Source Issue: 2
Topic: Temporal Scope: 2010 AD Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 220 Strategy & planning Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation; Company business planning
Organization: Organization: West Virginia State Medical Association
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 223908189

The WVSMA's recent Physician Practice Conference, held in conjunction with the Mid-Winter Conference, provided an exciting day of education for attendees. Physicians, administrators and other office personnel received the latest updates about the CPT coding changes for the New Year, as well as utilization and reimbursement updates that payors have made for 2010. Attendees learned effective strategies for improving their medical practices from Practice Management expert Rose Moore and Protocol Consultant Pam Harvit.

During the afternoon payor workshop, Patsy Hardy, Secretary of the Department of Health and Human Resources, and Nancy Atkins, Commissioner of the Bureau for Medical Services, joined the attendees and gave an overview of changes at Medicaid.

Dr. James Lee, of Connolly Consulting, the RAC (Recovery Audit Contractor) for Region C, provided guidance as to the status of the RAC's activities in West Virginia. Judging from the reaction of conference attendees, there still appear to be many questions about the RAC and how it will affect medical practices. Since the RAC activity in WV as of this date has been fairly minimal, it would seem a good time to review some of the information about the RAC.

As a review, Congress created the recovery audit contractors (RAC) program to help the Centers for Medicare and Medicaid Services (CMS) identify improper payments made by Medicare. The RAC contractors are private entities that are retained by the government to identify and recoup overpayments made to physicians and other healthcare providers, as well as to identify and return underpayments.

First created as a demonstration program, the RAC was subsequently expanded as a permanent nationwide program. The Tax Relief and Health Care Act of 2006 (TRHCA) authorized permanent RACs by January of 2010. The RAC program focuses on traditional Medicare Fee for Services and does not audit Medicare managed care plans. The RACs review claims on a post-payment basis and are paid a contingency fee for each inappropriate payment identified and recovered. It is important to note that the RAC will check for "excluded" (claims that were previously reviewed by another entity) before a claim is selected for audit. Also, the RAC will not pursue overpayments of less than $10.00 nor will they identify underpayments of less than $1.00.

There are limits to how far back a RAC may audit claims. Only claims which were paid as of October 1, 2007, and forward may be reviewed. In addition, the claim may not be audited more than three years past the claim paid date.

The RACs are also limited as to how many charts they may request per physician. For a solo practitioner, the RAC may only request 10 medical records every 45 days per NPI. For a partnership of 2-5 practitioners, the limit is 20 medical records every 45 days per NPI. For small groups (6-15), the limit is 30 every 45 days per NPI, and large groups (16+ practitioners) may have 50 medical records requested every 45 days per NPI.




If the RAC finds an overpayment, physicians have a number of options to return any monies. You may pay by check, allow withholding from future payments, or request an extended payment plan. If the overpayment is questioned by the physician, he/she may file an appeal. It is advisable to pay back the money before appealing, since interest must be paid on any outstanding monies if the physician should lose the appeal.

Physicians can prepare and ensure that they are ready for the RAC in several ways. They can conduct an internal assessment to identify if they are in compliance with Medicare rules and if not, they can identify corrective actions to implement for compliance. Also, all practices should have a contact person for the RAC and send the contact person's name and address to Connolly Healthcare.

For more information about the RAC, you may visit Connolly Healthcare at their website www.connollyhealthcare, or contact them at 866-360-2507. You may also obtain additional information from the CMS website, www.cms.hhs.gov/RAC/. For a quick response, RAC questions may be addressed to RAC@cms.hhs.gov.

I hope this information is helpful as you and your practice prepare for the RAC implementation.

Barbara Good

WVSMA Physician Practice Advocate
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