Nothing is ever easy for providers in the ever-fluctuating realm of recovery audit contractors, and the latest spell of operational hiccups heard nationwide is no exception.
No hospital necessarily wants to receive an additional documentation request (ADR) from the RAC, yet when it arrives, it's essentially not surprising. But when a provider receives a follow-up letter from that RAC informing the facility that the claim is closed and the audit has been rescinded, it may throw that hospital for a loop, according to a revenue integrity auditor from a hospital in Region A (DCS).
"We recently received an automated letter notifying us that Medicare made an overpayment related to a CCI edit with an amount and brief description of the claim associated with the overpayment," she says. "When I called [the RAC] to question the letter, a customer service representative told me that they'd rescinded the audit because it was 'outside their audit scope.' "
She continued, "I had to ask for a rescind letter to be sent to me stating this information. We are monitoring the account to assure that money isn't recouped by NGS on day 41, and this has prompted us to do an internal investigation related to this information."
A fellow revenue integrity auditor from a hospital in Region B (CGI), had a similar situation:
"We received an ADR and on the day we were ready to send out the records, we received an additional ADR from CGI stating 'please discard the previous letter,' " she says. "I believe it was a clerical error because they switched those accounts under 'complex reviews being considered' to 'complex reviews approved,' and those under 'complex reviews approved' to 'complex reviews being considered.' "
Although this issue is trending up as of late, it's something that's been around for a while, according to a compliance officer at a Georgia hospital in Region C (Connolly).
"Out of 187 records requested, we've had six statuses changed to 'claims closed – not eligible for review,' but these came in the early stages of RACs, and we haven't had any over the past few months."
The burning question for these hospitals and any facility that has experienced similar circumstances is "Why are the RACs doing this?" There may in fact be a number of perfectly logical reasons for RACs to rescind requests, says Keisha Patterson, RAC coordinator at Saint Joseph's Hospital of Atlanta.
- Untimely review. "If we did not review a request within 60 days of receipt and notify the provider, [the request] would have to be rescinded. We rescinded hundreds of reviews for this reason," she says.
- Wrong provider type requested. This happened during the demonstration as well as during the current permanent project, according to Patterson. RACs would request records from critical access hospitals when they are not paid via the same reimbursement methodology as OPPS acute care hospitals. "In my experience, they were inadvertently selected by the RACs as they failed to exclude their provider type for some audits."
- Faulty audit concept. "The erroneous selection of claims due to a faulty audit concept or inaccurate data analysis is also something I've witnessed," she says. "For example, one RAC may have incorrectly selected claims for an audit concept that is approved, but was written incorrectly in their query."
- Requesting above published limits. During the demonstration, if a RAC requested more than 200 records per 45 days they would have to rescind any requests over that 200 mark, and this would occur due to a number of technical glitches at times, according to Patterson.
Patterson is in a position to know. She worked at a RAC for three years during the demonstration period.
James Carroll is associate editor for the HCPro Revenue Cycle Institute.