On its website, CMS answers the following questions about recovery audit contractors.
Question: Can a recovery audit contractors review a claim more than once?
CMS: Beginning Nov. 1, 2010, if the RAC has already requested documentation and issued a review results letter to the provider for a DRG validation, the RAC would be allowed to re-review the claim again for medical necessity. However, if both issues are approved —– DRG Validation and medical necessity — prior to the request of the additional documentation, the RAC may also conduct both reviews simultaneously. Each additional documentation request is subject to the same review timeframes and counts toward the provider's ADR limit.
Q: Can the recovery audit contractor do a medical necessity review on a claim that it originally reviewed for DRG validation?
CMS: If the RAC has already requested documentation and issued a review results letter to the provider for a DRG validation, the RAC will be allowed to re-review the claim again for medical necessity. However, if both issues are approved prior to the request of the additional documentation, the RAC may also conduct both reviews simultaneously. As stated before, each additional documentation request is subject to the same review timeframes and counts toward the provider's ADR limit.
Q: Will the recovery audit contractors review evaluation and management services on physician claims under Part B?
CMS: Yes, the review of all evaluation and management (E & M) services will be allowed under the RAC program. The review of duplicate claims or E & M services that should be included in a global surgery were available for review during the RAC demonstration and will continue to be available for review. The review of the level of the visit of some E & M services was not included in the RAC demonstration. CMS will work closely with the American Medical Association and the physician community prior to any reviews being completed regarding the level of the visit and will provide notice to the physician community before the RACs are allowed to begin reviews of E&M services and the level of the visit.
Read the three questions about RACs on the CMS website.
Related articles on RAC policies:
When RACs Deny Inpatient Stay, Appeal is Only Way to Get Paid
RAC Denials Based on Incorrect Dosages: Q&A With Elizabeth Lamkin
RAC Demands Can Expose Rifts Between Hospital, Physicians