As mentioned in the previous post in this series, when the RACs take back the revenue from a claim, they take back 100%, and the provider cannot refile — except, during the demonstration project, in the case of a claim for inpatient therapy following a single knee replacement at an Inpatient Rehabilitation Facility (IRF). Even then, as we noted, the report is not clear about this exception and its application, much less what will happen in the future.
In the RAC Evaluation Report, however, there is this interesting notice, under section 6, entitled, “Lessons Learned from the RAC Demonstration”:
ISSUE #4: Hospitals could not resubmit claims
when necessary services were provided in the
wrong setting.
CHANGE: During the RAC demonstration, CMS
waived the “timely claim filing” limits and allowed
hospitals to resubmit claims for outpatient ancillary
services in these situations. CMS is exploring
whether it is possible to continue this waiver during
the RAC permanent program.
There is no further explanation, no discussion, no notes, and nothing has appeared as yet to update that notation.
Given how much the RACs are “recovering,” we have doubts they will do much beyond this scenario, perhaps because of the difficulties involved in meeting the mandated criteria, as outlined in the the published requirements (again, see HCFA Ruling 85-2 and Medicare Benefit Policy Manual Section 110 ).
Next, we will examine some of the other “Lessons Learned” to glean more about what the RACs will be watching. Actually, we have a complete course about “Documentation Hot Spots” that the RACs are sure to pursue.
See the course on our eVehicle, at www.myedutrax.com.
recovery audit contractor
