As part of the upcoming recovery audit contractor program for Medicare Part C, involving payments by Medicare Advantage plans, the AHA wants CMS to impose 15 requirements on Part C RACs, according to a letter from AHA to CMS Administrator Donald M. Berwick, MD.
1. Exclude medical necessity review from the program. But if such reviews are allowed, ensure a mechanism for hospitals to re-bill for services that were medically necessary but provided in the wrong setting.
2. Make sure trained medical professionals conduct RAC audits.
3. Limit RACs to a 12-month look-back period.
4. Require close CMS oversight. Assign specific CMS staff to address provider concerns.
5. CMS should approve each audit issue before a RAC can conduct an audit.
6. Invest income in program improvements and provider education. Invest at least 7 percent of funds from RAC recoveries into payment system fixes and provider education.
7. Exact penalties for RACs that duplicate audits and apply incorrect payment rules.
8. Implement a medical record request limit. In Medicare Advantage audits, some hospitals have been receiving requests for every single claim paid by a plan.
9. Require RACs to provide a case-specific rationale for each denial.
10. Create timeframes for RACs to make determinations and notifications to providers.
11. Extend the provider's response time when RAC correspondence is sent to the wrong organization.
12. Require RACs to establish websites showing approved audit issues, customer service contact information, tracking of open audits and providing a portal for hospitals to submit contact information.
13. RACs should respond to provider inquiries within 24 hours.
14. Require an appeals process with multiple levels and use of a discussion period similar to that in the Medicare fee-for-service RAC program.
15. Suspend RAC recoupment until appeals are exhausted and withhold RAC contingency fees when a denial is overturned.
Read the AHA letter to Don Berwick, MD about Medicare Part C RACs (pdf).
1. Exclude medical necessity review from the program. But if such reviews are allowed, ensure a mechanism for hospitals to re-bill for services that were medically necessary but provided in the wrong setting.
2. Make sure trained medical professionals conduct RAC audits.
3. Limit RACs to a 12-month look-back period.
4. Require close CMS oversight. Assign specific CMS staff to address provider concerns.
5. CMS should approve each audit issue before a RAC can conduct an audit.
6. Invest income in program improvements and provider education. Invest at least 7 percent of funds from RAC recoveries into payment system fixes and provider education.
7. Exact penalties for RACs that duplicate audits and apply incorrect payment rules.
8. Implement a medical record request limit. In Medicare Advantage audits, some hospitals have been receiving requests for every single claim paid by a plan.
9. Require RACs to provide a case-specific rationale for each denial.
10. Create timeframes for RACs to make determinations and notifications to providers.
11. Extend the provider's response time when RAC correspondence is sent to the wrong organization.
12. Require RACs to establish websites showing approved audit issues, customer service contact information, tracking of open audits and providing a portal for hospitals to submit contact information.
13. RACs should respond to provider inquiries within 24 hours.
14. Require an appeals process with multiple levels and use of a discussion period similar to that in the Medicare fee-for-service RAC program.
15. Suspend RAC recoupment until appeals are exhausted and withhold RAC contingency fees when a denial is overturned.
Read the AHA letter to Don Berwick, MD about Medicare Part C RACs (pdf).