HFMA ANI 2009: News and advice from the RAC front

It's not enough that Medicare's Recovery Audit Contractor program is going into full swing--CMS is also making some changes as it steams into its national rollout. Here's an update on some of the changes, as well as ongoing issues to bear in mind, from a talk given this week at the HFMA ANI show by Conifer Health Solutions' Rudy Braccili Jr., MBA, CPAM. (Braccili is senior director of the vendor's National Medicare & Medicaid Center.)

All told, from Braccili's account, the latest from the RAC program offers a mix of good and bad news, including the following:

* On the good news front, RAC contractors are now officially getting their 12 to 13 1/2 percent incentive to find underpayments to providers as well as overpayments. In the past, they were only going after overpayments, a mandate that raised cries that they had incentives to trump up issues and bury providers in paperwork.

* Another piece of good news that offers providers a breather: While the RACs will eventually review for both coding/billing errors and medical necessity, CMS has announced that the RACs won't begin to do medical necessity reviews until 2010.

* The four RACs are now being required to keep a list of areas they're watching, then publish it on their respective websites. They can only pursue a clinical area if they get permission from CMS, but once a single RAC gets that permission, you can assume that the others will follow suit, Braccili notes. For that reason, it's important to check all four sites regularly, he says.

One critical issue that Braccili covered in depth was the problem of when to appeal a decision. As other speakers at HFMA have noted, providers who prepare carefully can win their appeals in many cases.

On the other hand, it's not a good idea to appeal accusations of overpayment unless you're pretty sure you have a good case, Braccili suggests. The reason? If you take your appeal through two levels, and you lose, CMS will hold back the amount you owe, plus a stiff interest penalty. Besides, according to AHA estimates it can cost anywhere from $3,000 to $7,000 to appeal a claim, he notes.