rac restart how to clean up your old denials. agenda cms restarts parts of the rac program how to...
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CMS Restarts Parts of the RAC Program CMS is restarting the controversial RAC Program Limited fashion Starts in August Medicare fee-for-service claim reviews 3TRANSCRIPT
RAC Restart
How to Clean up your Old Denials
Agenda
• CMS Restarts Parts of the RAC Program
• How to Clean up your Old Denials – Through CMS’s statistical sampling opportunity
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CMS Restarts Parts of the RAC Program
• CMS is restarting the controversial RAC Program• Limited fashion• Starts in August • Medicare fee-for-service claim reviews
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CMS Restarts Parts of the RAC Program
• Current RAC Auditors will conduct:– A limited number of automated reviews and– A small number of complex reviews on certain
claims including, but not limited to: • spinal fusions, outpatient therapy services,
durable medical equipment, prosthetics, orthotics and supplies; and cosmetic procedures
– The Recovery Auditors will not conduct any inpatient hospital patient status reviews during this limited restart period
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How to Clean up your Old Denials
• Office of Medicare Hearings and Appeals (OMHA) announced a way to clear up the ALJ backlog
• Statistical Sampling Pilot Program• If you have more than 250 claims subject to appeal• CMS statistical sampling game• If you meet all of the criteria and choose to
participate, OMHA will assign an independent statistical expert to assist the Administrative Law Judge (ALJ) in “carrying out the statistical sampling in accordance with Medicare guidance.”
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How to Clean up your Old Denials
• In cases in which an ALJ appeal has been filed:– 80% of the overpayment findings were reversed in
favor of the provider• The majority of the extrapolations also have been
vacated because the “statistical expert” utilized by the auditor failed to actually produce a statistically valid random sample
• And they don’t have to….
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How to Clean up your Old Denials
• Chapter 8 of the Program Integrity Manual – Touches on the concepts of statistical sampling
and extrapolation– Allows for a huge amount of latitude– Sampling can be flawed and there is nothing the
provider can do about it
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How to Clean up your Old Denials
• Should a provider wait and deal with the ALJ with an 80% win rate for the provider or face the flawed statistical sampling from CMS?
• The ALJ is independent, CMS is not, so who would you rather place your fate in?
• Depends on your circumstances, but most providers would be better off waiting for the ALJ
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ByRebecca Corzine Tarr RN CPA
Executive Vice President MedPerformance LLC
Questions/Comments?
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