It seems that many providers still struggle to understand the Recovery Audit Contractor discussion period that CMS has helpfully given them—much less take advantage of it when the permanent program rolls out in their area.
The discussion period is new to the permanent program, though it is somewhat akin to the rebuttal period, which was part of the demonstration program.
"The rebuttal period was used in the demonstration because it is part of the Medicare appeals process," says Camille Cohen, MBA, CHC, compliance manager at 3M Health Information Systems in Salt Lake City.
But CMS found providers had a slightly different need from the rebuttal process during the demonstration project, she says. Originally designed to discuss mathematical errors, providers instead used the rebuttal period for all kinds of discussions. Hence, CMS decided to initiate the discussion period specifically for RACs.
"The RACs and CMS are trying to work with providers, and the discussion period is a huge open door for providers to have a dialogue with their RAC," Cohen says.
Providers can use this chance to communicate with their RACs to discuss much more than math. Not only can they use it to try to change the RAC's mind on a denial, but they can use it as a learning opportunity. A RAC may discuss how it came up with the determination. Providers should seek out that information so they don't keep making the same mistakes, says Cohen.
That information may also be helpful during the appeals process, she says. "But the discussion period doesn't lengthen in any way shape or form the appeals process and it doesn't take the place of the appeals process," she reminds us. "All it does is open up the dialogue with the RAC to hopefully take care of problems such as missing or incomplete documentation before you have to go through the appeal process."
In addition, some RACs have indicated during outreach sessions that they will accept missing documentation. "CMS emphasized providers shouldn't go create documentation, but if a provider has documentation, but it is missing from the information received by the RAC, some RACs will accept the missing documentation after the fact," Cohen says. For example, if a physician discharge summary had been dictated, but never filed—the RAC would likely accept that during the discussion period, she says.
The discussion period has two different start times, depending on whether it is for an automated or complex review. With an automated review, the provider finds out there has been a review and a denial when it receives a demand letter from the RAC. Receipt of that letter kicks off the discussion period. But for complex reviews, the discussion period begins when the provider receives the review results letter, which would arrive prior to the demand letter, giving the provider additional time to discuss the denial with its RAC. The discussion period ends upon recoupment of the money (i.e., day 41) regardless of the type of review.
But providers shouldn't wait until day 39 or 40 to contact their RAC. "CMS was very careful to say to providers that they should contact their RAC as soon as possible during the discussion period because it doesn't stop the recoupment," Cohen says. "But if the provider can quickly convince the RAC that an error was made in denying the claim during the discussion period, and the demand/remittance step isn't initiated, there may be the opportunity to stop the process."
To effectively and efficiently take advantage of the RAC discussion period, Cohen recommends providers do the following:
Group similar denials whenever possible. Use your tracking database to group issues and then talk about them globally. "That way, when you talk to your RAC, instead of having 200 issues to discuss, you have 10. You'll probably be a lot more successful."
Stay organized. Especially when it comes to complex reviews, organization is critical. Use tracking databases or spreadsheets to document and track denials. They will help you keep on top of deadlines and recognize commonalities between denials that may help identify whether a claim is defensible during the discussion period or appeals process, or when you need to correct an error.
Use strategy. "You'll only want to go to the RAC during the discussion period for those claims you really feel like you want to defend," says Cohen. "I'd avoid calling them with 50 claims and asking the RAC to go through each one to explain why they denied it. I'm not sure you want to spend that much time, much less the RAC."
Don't get sidetracked. Providers should use the discussion period, but shouldn't let it distract them from determining whether they want to appeal the claim, or given the early deadlines they need to meet, if they want to stop recoupment (e.g., they can appeal by day 30). There are many decisions providers need to make, Cohen says. So it is important that they don't let the discussion period distract them too much from everything else that needs to be done.