Ask the payment expert ... about continuing RAC requests

Share this article:
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. 



Share this article:

More in News

Rape investigation blocked by nursing home's HIPAA concerns, authorities say ...

Florida authorities say a nursing home is citing privacy laws to impede the investigation of a possible resident rape, according to local news reports.

Jury hands down $14 million negligent care verdict to 'send message' to nursing homes

Jury hands down $14 million negligent care verdict ...

A Massachusetts jury has awarded $14 million to the family of a nursing home resident who died due to a pressure ulcer, dehydration and other conditions linked to negligent care, ...

CCRC executive director salaries hold steady, therapy directors get boost

Continuing care retirement community executive director salaries have barely increased in the past year, while therapy and rehabilitation directors received a boost, a new report shows. The average salary for a therapy and rehab director is currently $95,905.