Medicare Compliance & Reimbursement

Stay on top of RAC requests so you're able to meet all request deadlines.

Recovery audit contractors (RACs) can retroactively deny your claims for a number of reasons -- but one that can easily be remedied is lack of medical documentation on your practice's part.

If a RAC requests your medical documentation and you don't send it -- or you submit incomplete or illegible records -- your payments can be denied. Plus, money that your MAC already sent to you can be recovered back to the carrier in cases of nonexistent or incomplete documentation.

The issue of incomplete documentation was identified by CMS recently as a "high dollar improper payment vulnerability," and the agency issued MLN Matters article SE1024 to discuss the topic and explain to providers that documentation should be a top priority.

"Coders should be catching insufficient documentation before a claim leaves the office, but in some cases, it's caught by RACs on the back end -- after a claim has already been reimbursed," says Atlanta-based coding consultant Jay Neal. "If you know you're missing documentation, you really shouldn't bill for the service in the first place, or you could have to reimburse that money down the road."

Your practice isn't the only party in the RAC-provider relationship that has to play by the rules. The RACs are required to stay within the following guidelines when requesting documentation from medical providers, according to the MLN Matters article:

• The RAC must indicate the deadline by which you have to submit your medical records;

• The RAC must contact you one additional time before denying your service based on lack of documentation;

• If you can't submit your documentation in a timely manner, the RAC must accept and review extension requests;

• The RAC should suggest which types of documentation will help its employees adjudicate the claim;

• The RAC must accept medical records on CDs, DVDs, or via fax;

• RACs can only look back at your records for a three-year period, with a maximum look back date of Oct. 1, 2007;

• RACs have to limit the number of medical requests every 45 days;

• The RAC must indicate the status of the provider's additional documentation request on its claim status website;

• The RAC has to maintain a provider web portal where providers can customize their address and find the correct point of contact; and

• The RAC must post all approved issues under review on its Web site.

(Editor's note: To read the MLN Matters article, visit www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf.)