Recovery Audit Contractor (RAC) Demonstration High-Risk Vulnerabilities No Documentation or Insufficient Documentation Submitted

WCH would like to inform you of the recent news from Medicare Learning Network. Please review the article and take steps, if necessary, to meet Medicare's documentation requirements to avoid unnecessary denial of your claims.

RAC demonstration proved recovery auditing was successful identifying and correcting improper payments in Medicare and allowed CMS to identify high risk vulnerabilities. Two of the high risk vulnerabilities identified during the RAC demonstration:

• Provider non-compliance with timely submission of requested medical documentation; and
• Insufficient documentation that did not justify that the services billed were covered, medically necessary, or correctly coded.

CMS reminds providers that medical documentation must be submitted within 45 days of the date of the Additional Documentation Request (ADR) letter. If a provider fails to submit documentation, there is no justification for the services or the level of care billed. Failure to submit medical records (unless an extension has been granted) results in denial of the claim. Also there must be sufficient documentation in the provider's records to verify that the services were provided to eligible beneficiaries, met Medicare coverage and billing requirements, including being reasonable and necessary, were provided at an appropriate level of care and correctly coded. If there is insufficient documentation for the services billed, the claim may be considered an overpayment and the provider may be requested to repay the claim paid amount to Medicare.

The following requirements have been developed to assist providers in ensuring the timely submission of sufficient documentation to justify the services billed:

• RACs must clearly indicate deadlines for submission of medical records in ADR letters;
• RACs must initiate one additional contact with the provider before issuing a denial for a failure to submit documentation;
• RACs must accept and review extensions requests if providers are unable to submit documentation timely;
• RACs must clearly indicate in ADR letters suggested documentation that will assist them in adjudicating the claim;
• RACs must allow providers to submit medical records on CD/DVD or to fax the needed medical records;
• RACs must implement the RAC look back date of 3 years with a maximum look back date of October 1, 2007;
• RACs must limit the number of medical records requests every 45 days;
• RACs must indicate the status of a provider's additional documentation requests on their claim status websites;
• RACs must establish a provider web-portal so providers can customize their address and identify an appropriate point of contact to receive ADR letters;
• RACs must post all approved issues under review on their websites.

CMS recommends providers implement a plan of action for responding to RAC ADR letters (tracking audit and appeal findings, identifying patterns of error, implementing corrective actions). Providers should also consider monitoring their RAC websites for updates. This will assist providers in better understanding what audits are taking place so they can prepare to respond to ADR letters.

The following list identifies information unique to each of the four RACs, the States they cover, their subcontractor(s), and includes website information to assist providers in preparing for RAC audits:

RAC Region A- Diversified Collection Services (DCS), Inc. of Livermore, California:

States in Region: Maryland (MD), Washington, D.C., Delaware (DE), New Jersey (NJ), Pennsylvania (PA), New York (NY), Maine (ME), Vermont (VT), New Hampshire (NH), Massachusetts (MA), Connecticut (CT), and Rhode Island (RI).

Subcontractors: PRGX (formerly PRG Schultz), Federal Review Services, and iHealth Technologies

Email: Info@dcsrac.com

Website: http://www.dcsrac.com/portal.html

Sincerely.

WCH Billing Department