Ask the payment expert ... about continuing RAC requests

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Ask the payment expert ... about the observation stay loophole
Ask the payment expert ... about the observation stay loophole

I thought the Recovery Audit Contractors (RACs) were on hold. Why did we still get a request for records? 

There could be several reasons. First, if you have a claim already in the RAC process and you have appealed, the process will continue. Only new RAC reviews will not begin during the “pause.” The appeal process includes a Redetermination, Reconsideration and then the Administrative Law Judge  hearing. There are specific time frames for each of those steps, and at the present time, the ALJ hearings are backed up about three years. If a claim is in the process, continue with the appropriate timeframes if you want to appeal the denial. The “pause” does not change those timeframes. 

The second reason you might get a request for documentation is that another contractor may be making the request. Medical reviews from your Medicare Administrative Contractor (MAC) are still ongoing. In addition, you could have a review from a MIC (Medicare Integrity Contractor), ZPIC (Zone Program Integrity Contractor), CERT (Comprehensive Error Rate Testing), PERM (Payment Error Rate Measurement) or a SMRC (Supplemental Medical Review Contractor). The government has multiple ways to assess your facility for fraud or abuse, including overpayment of claims. 

The lesson here is to make sure you have good systems and processes in place to minimize your risk of denials. You need to make sure your documentation is pristine in showing the skilled care you are providing and the reason  the resident needs it in your facility. This is especially important for therapy, which is the main service denied as a result of medical review. I strongly suggest you consider having an annual Medicare assessment of your facility to have an objective opinion of your risk for denials and to improve practices. 



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