On March 6, KHA will host a webinar s devoted to reviewing the current status of Recovery Audit Contractor (RAC) activities along with due consideration to the new contracts, scope of works, and various RAC approved issues.

Included in this program will be recent events surrounding the RACs and the backlog of appeals at the Administrative Law Judge (ALJ) and Medicare Appeals Council (MAC) level. OMHA has proposed several different ways to address their enormous backlog of appeals including statistical extrapolation, settlement conferences, and administrative agreements. One of the main issues is that of medical necessity for inpatient admissions. The inpatient issues have sparked the development of the ‘Over 2-Midnights’ rule. CMS has also proposed changes to the appeals process in order to expedite the resolution of the backlog of appeals. The expansion of the RACs to the Medicare Advantage Programs is still in the works with the Risk Adjustment Data Validation (RADV) with a concentration on both comprehensive...

On August 18, the Centers for Medicare and Medicaid Services (CMS) held an Open Door Forum to discuss hospitals and hospital quality. During the forum, CMS addressed short stay policies.

Officials noted that, in conjunction with proposals in the calendar year (CY) 2016 Outpatient Prospective Payment System (OPPS) Proposed Rule, the Agency has extended its probe and educate review period through December 31.Beginning October 1, quality improvement organizations (QIOs) will take over initial reviews of claims for patient status based on current policies. As of January 1, QIOs and recovery audit contractors (RACs) will carry out reviews based on any policies adopted through the OPPS final rule.

CMS said QIOs will conduct reviews and education sessions in a collaborative manner with providers and will only refer cases to recovery audit contractors (RACs) for further review if there is evidence of a pattern of high levels of short stay claims denials, if a hospital does not respond to educational outreach or if there is some potential of fraud or abuse. The Agency acknowledged that there are questions about parameters for review and how referrals will be made and said more information will be forthcoming.

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On April 7, the Centers for Medicare and Medicaid Services (CMS) held its regular Open Door Forum (ODF) devoted to hospital and hospital quality issues. The Agency reminded providers that it has extended its "Probe and Educate" program related to Recovery Audit Contractor (RAC) review of hospital inpatient claims through April 30. As of now, relevant claims with dates of service from October 1, 2013, through April 30, 2015 are not subject to formal review by RACs. Though that would lapse as of May 1, 2015, CMS noted that legislation before Congress would extend the period through fiscal year (FY) 2015.

Other topics included wage index appeals, open payments review and coverage of CT scans for lung cancer.

A summary of the Forum from Health Policy Source is available at http://www.new-kyha.com/Portals/5/NewsDocs/ODFSummary040715.pdf.

Below are several important pieces of information regarding AHA's data collection of hospitals’ experience with Recovery Audit Contractors (RACs).

Standalone RAC administrative burden survey Hospital chief executive officers have been sent a link to an AHA survey that attempts to gain greater insight into the resources – both financial and staff time – that hospitals are utilizing to comply with RAC audits. These hidden expenses, beyond the value of recoupments, are important to measure in order to illustrate the total cost of RAC audits to hospitals. This survey is separate from the RACTrac survey. The deadline for the survey to be completed is September 19.  

RACTrac update to be launched in October reporting period AHA has undertaken a substantial revision of the RACTrac survey in order to gain important information on key advocacy areas, including rebilling and appeals. In support of this effort, the AHA’s claim level tracking tool has been updated for hospitals to...

Congressional support for reforming the Centers for Medicare and Medicaid Services’ (CMS) Recovery Audit Contractor (RAC) program continues to grow. Currently, 221 representatives – a majority of the House – have signed on to support the AHA-backed Medicare Audit Improvement Act (H.R.1250/S.1012). Kentucky Congressmen Andy Barr, Brett Guthrie, Thomas Massie, Hal Rogers and Ed Whitfield have all lent their support to the legislation.

Now is a great time to thank those Congressmen who have joined this effort and to reach out to those who have yet to sponsor the Act. Senators Mitch McConnell and Rand Paul and Congressman John Yarmuth are not currently sponsors.

For further information, please contact Sarah S. Nicholson at KHA (502-426-6220 or 800-945-4542 or via e-mail at snicholson@kyha.com).

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