Medicare Compliance & Reimbursement

There's no question about it -- the Medicare program's Recovery Audit Contractors are armed and ready to sweep the greater medical community, no matter where you live or how large or small your practice might be.

In their three-year pilot, RACs racked up a whopping $1 billion in corrected overpayments, and they're not stopping there. These medical review bounty hunters are rolling out in 24 states now and will start activities in the remaining states in August.

Stay alert: "If you're submitting claims to Medicare, it's 100 percent odds that you'll be audited," cautions Tim Johnson of Castle Rock Medical Group, a Denver-based consulting firm that specializes in RACs.

It might not happen right away since the contractors will target high-dollar claims first, but as the RACs become more efficient, "the lower they'll drill down," Johnson predicts.

Experts recommend these tips to minimize RAC review fallout:

If a RAC contacts you with a medical records request, you have 45 days to submit your data, or you get an automatic denial, says Linda Baumann, attorney with Arent Fox in Washington, D.C. "It may sound like a lot of time, but a lot of people are missing this."

This task might become even harder when your staff is faced with requests from unfamiliar contractors in unfamiliar formats.

Looking ahead: "Make sure that you have all of your processes in place and all of your documentation in order so that if auditors are addressing issues you don't feel are substantiated, you're ready for the appeal process," counsels attorney Cherilyn G. Murer of Murer Consultants in Joliet, Ill. "In these early days, the appeal process is critical; this is the time to be aggressive with the audit and with the appeal because we're setting the stage at this time," she adds.

This may take re-education, but it's well worth the time you spend with your physicians and staff.

"You have to ... over-exaggerate documentation relevant to medical necessity," Murer stresses. "We've always said documentation is important, but right now it is at the essence of our survival."

HHA caution: Home health agencies "have gone quite a few years without much oversight," notes William Dombi with the National Association for Home Care & Hospice. This means their documentation is likely to be more at risk.

Target tip: Focus on reinforcing any documentation for high-risk areas like therapy, suggests therapist and consultant Cindy Krafft with Fazzi Associates in Northampton, Mass. "If the documentation cannot support medical necessity, a downcode becomes an overpayment," Krafft warns.

"Protection is being prepared," Krafft points out. "Routine internal audits of content ... can be very beneficial in risk reduction."

Don't expect rigorous internal auditing to stave off RAC reviews, however.

"Readiness will never keep an audit away," she points out. "It will allow an agency to enter into one with more confidence and the ability to defend the care, as opposed to crossing fingers and hoping you don't get picked."

For an effective appeals battle, base your arguments on Medicare payment criteria and say how your claims fulfilled specific criteria.

Smart move: If you choose to appeal a RAC denial, develop a "criteria-based summary," Johnson recommends.

"The courts have held that when Medicare has specific criteria, it must use that criteria to evaluate cases." So take the medical record and the documentation you want to appeal, line it up next to your reimbursement criteria, and build a case summary that points to how each requirement was met, Johnson explains.

If it comes down to you fighting for your money in higher levels of appeals, watch how you are presenting your case. An administrative law judge probably doesn't have a medical background.

"There's a tendency for ... people to assume that the courtroom understands as much about the patients and patient care as they do," says attorney Donna Thiel with Baker, Donelson, Bearman, Caldwell, & Berkowitz in Washington, D.C. "So I urge providers to tell the story of the patient, to really paint a picture of this person and what's going on."

Important: Be particularly careful about jargon. As everyday as specific medical terms sound to you, they won't to a judge.

Don't assume the ALJ understands Medicare coveragecriteria either. "You may be facing a new judge ... so you don't want to start talking about how you fulfilled coverage criteria until you explain what the coverage criteria are," Thiel says.

You may have heard the stories of all the appeals won at the ALJ level during the RAC pilot project. Although this is a high level in the appeals process, it's not the last.

"We are finding multiple cases where the Medicare appeals council is overturning ALJ decisions," Johnson points out.

Bottom line: Don't breathe a sigh of relief until all five levels of appeal are exhausted.