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AHA Issues Member Advisory on RAC Program

Andrea Kraynak, CPC-A, April 22, 2009

With so many Medicare reimbursement dollars at stake, it is no surprise that everyone is putting in their two cents. Make no mistake—the wealth of information becoming available is a good thing. The more you know about the Recovery Audit Contractor program, the better you will be able to manage the process.

Most recently, the American Hospital Association is sharing what it knows via a Member Advisory released April 20. The publication, "Medicare Recovery Audit Contractors (RACs): Permanent Program Basics," (available to AHA members on the organization's Web site) contains a wealth of RAC-related information for healthcare providers.

"With the RAC program in the process of rolling out nationally, it is crucial for hospital executives to use tools like this to help educate themselves on the permanent program," says Robert Corrato, MD, MBA, founder, president, and CEO of Executive Health Resources. "There have been some changes since the RAC demonstration, which we have seen result in confusion for many hospitals across the country."

While the Advisory discusses a wide variety of RAC-related topics, healthcare providers may find useful the information on medical record request limits—a topic many organizations find confusing. And CMS has left its options open to alter the current medical record request limits in the future.

Interestingly, the AHA notes that while hospital campuses with more than one NPI are currently capped at 200 medical records per 45 days, this could change. "[CMS] will be looking at organizations with multiple NPIs closely to ensure that the organizational structure does indeed warrant a cap of 200 medical records. It is not CMS' intent to have multi-hospital systems subject to a cap of 200 medical record requests per 45 days," according to the Advisory.

CMS has not yet updated, or clarified, this information on the RAC Web site, notes Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc. She suggests that hospital systems, which this may affect, should keep an eye on the CMS Web site for more information.

In addition, RACs will communicate the medical record request limit for each healthcare organization in its initial medical record request letter, according to the Advisory. Make sure your RACs number matches up with the one you've calculated for yourself.

RACs may not "supersede" medical record request limits by "bunching" requests, according to the Advisory. In other words, think of cell phone plans featuring rollover minutes. Unlike such a plan, RACs can't store unused requests and roll them over for later use. The AHA uses the following example:

If the medical record request limit for a particular provider is 50 per 45 days and the RAC does not request medical records in January and February, the RAC cannot request 150 records in March.

Finally, RACs may request a limited number of records related to issues they will target for claim reviews not yet approved by the New Issue Review Board, and thus not listed on the RAC Web sites as areas RACs will review. The AHA Advisory explains:

CMS requires a RAC to present data analysis or other evidence of improper payments before it proceeds in wide-scale review of claims. In order for the RAC to compile that information, CMS will allow each RAC to request a limited number of medical records from hospitals before the new issue has been approved. CMS has indicated that no more than 10 medical records per provider can be requested for any particular issue before it has been approved by the New Issue Review Board.

Remember that RACs must make the status (e.g., outstanding, received, underway, completed) of requested records available upon request. Each RAC will have a toll-free number for this purpose. CMS is requiring each RAC to have a Web-based application for this purpose developed by January 2010.


Andrea Kraynak, CPC-A, is managing editor of The RAC Report, the Coding Educator, and for HCPro's Revenue Cycle Institute. She may be reached at akraynak@hcpro.com.

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