RAC rollout: Details trickle in

BALTIMORE - CMS officials revealed a few new details on the Recovery Audit Contractor (RAC) program during a Special Open Door forum Tuesday, including how many medical records contractors can request.

New details on the program, set for a nationwide rollout on Jan. 1, 2010, include:

• The number of medical records a RAC can request from a provider is limited to 1% of the provider's average Medicare monthly services, with a cap of 200 records per 45-day period. Providers can submit medical records by CD/DVD, fax or mail (they need to contact their RAC to determine technical compatibility). RACs must have a status Web site that will allow providers to ensure when and if requested medical records have arrived at the RAC. Providers will also be able to use the site to customize their contact information.

• CMS officials from the policy, coverage and appeals departments will assist the RACs in reviewing codes and services. If an issue appears to be widespread across a jurisdiction or the nation, the RACs, with CMS approval, can move forward with a larger review. To maximize transparency, the RACs must post updates to www.cms.hhs.go/rac.

The general tone of the forum: CMS is committed to a fair and equitable program, officials say.

"We want to minimize the provider's burden, ensure accuracy and maximize transparency," said Amy Reece, RAC project officer, Jurisdiction C.

The RACs will conduct two types of reviews: automated and complex. In an automated review, the RAC will look at claims to see whether a national or local coverage determination supports a possible improper payment.

In a complex review, providers will be asked to submit medical records to support the claim. They will have 45 days, plus a five-day mailing window on either end of that period, to comply. The RAC then has about 60 days to review the charts and conduct an audit. Once the audit is complete, the RAC will send a review results letter to the provider to let them know what they found on the audit.

For both types of reviews, providers have a discussion period if they disagree with the RAC's findings.

"Pick up the phone, call the contractor and discuss the case," said Kathleen Wallace, project officer, Jurisdiction D. "Find out what you need to support your claims and possibly disconnect the audit."

If a claim is not resolved, the RAC will issue a demand letter with remittance advice containing the code N432. Providers can pay by check, offset recoupment, request an extended payment plan or appeal.

The RAC cannot look back more than three years when reviewing claims, and it can go back no further than Oct. 1, 2007.