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Providers prep for return of RAC

Providers prep for return of RAC New contract, however, means several improvements to process

LIVERMORE, Calif. - Providers should strap in: After a protracted lull, RAC audits will likely pick back up in January, now that CMS has tapped Performant Recovery, based here, to perform post-payment reviews for DME and home health/hospice claims nationwide.

Stakeholders say Performant will likely kick-start its efforts with reviews* it had previously been performing as the RAC for Jurisdiction A—reviews whose targets were everything from vacuum erection devices to respiratory assist devices to portable oxygen systems to vents.

“I think one thing that we can glean is that, because the RACs need CMS approval for their reviews, to get started right away, they will carry over a lot of those previous reviews,” said Wayne van Halem, president of The van Halem Group.

CMS's award to Performant signals the agency's move to a single RAC for DME claims for all four jurisdictions. It initially planned to have this new structure in place in 2014, but it has been slowed down* by pushback surrounding changes* to the new contract and several protested awards, including an award to Connolly* in December of 2014.

Because Performant will be conducting post-payment reviews of DME claims paid during a three-year span, providers should be on the lookout that the RAC applies the correct coverage policies, stakeholders say.

“The biggest risk is, what version of the LCD are they looking at?” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “For repeat rentals and supplies patients, (the contractor) needs to be very aware of what's required when the patient actually received the services.”

While post-payment reviews are never pleasant, changes to the new contract mean several improvements for providers, including a more meaningful discussion period, stakeholders say. Previously, providers had the option of a discussion period, but because the RAC immediately signaled the MAC to start the overpayment process, the only way they could hold onto their money was to file an appeal.

“This is a true passing of the baton,” said Andrea Stark, a reimbursement consultant for MiraVista. “You get the results of the review and then you can sit on it for 30 days. You can provide counter evidence or missing evidence, all the while avoiding an overpayment going to the MAC (right away). That should be more effective.”

Other changes to the new contract that benefit providers: Performant can't collect contingency fees until the second level of appeals is exhausted, and it will be held to a 95% accuracy rate and a less than 10% turnover rate on appeal, stakeholders say.

“That forces them to be more comprehensive with their reviews,” van Halem said.

The only change to the new contract that could pose a problem for providers, stakeholders say: Performant is required to participate in 50% of hearings at the administrative law judge level, a provision CMS added as a result of the high overturn rate at the ALJ.

“When the contractor is there, there's a vested interest that the claim remain unpaid,” van Halem said. “That will be more challenging for providers.”


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