How Does The Rac Review Process Function?
Why Have Discussion?
The objective is, if feasible, to convince the RAC which you can offer extra information (documentation or some kind of written record) that will explain the claim much better, and show that payment from the claim as billed doesn’t violate any CMS rules or regulations.
If you can do this before the adjustment is made by your carrier/FI/MAC, the whole denial process stops for that claim. There is then no adjustment produced, and consequently no need to use the lengthy appeal procedure.
So it’s a window of opportunity, albeit undefined, and maybe woefully brief. For so-called automated reviews, it’s truly brief, but you’ve a longer window in the case of a complicated review.
Automated Review Discussion Period
Automated reviews and denials are determined by pure data evaluation of claims, and do not involve records critiques.
Really, records may be reviewed by the RAC and CMS to be able to determine that an issues exists, but that all occurs beforehand, and we are not talking about that procedure here. (To be clear, you will find instances where a RAC might request records as “samples.” A provider may get a letter requesting as much as ten records, but the letter will state that they are for the specific purpose of “sampling” records to investigate some suspected problem. These samples might later be used by the RAC to support the viability of performing automated reviews. That is a completely separate process. Because such “sample” reviews don’t directly generate a denial, there’s no report to the provider, no discussion period, and hence no appeals process.)
At any rate, a RAC doesn’t request medical records from a provider for purposes of conducting an automated review. They simply carry out evaluation, based upon a CMS approved issue, and problem a demand letter to the provider. Note that RAC Demand Letters will come from the RAC, and not from your carrier/FI/MAC, as happens for other kinds of audits and/or denials.
The Discussion Period for an automated evaluation begins on the date from the Demand Letter, and ends when the adjustment is made by the carrier/FI/MAC.
As soon as you get a Demand Letter from the RAC, you should take a look at the claim and decide as soon as you possibly can if you disagree with the RAC’s conclusion. If you disagree, you need to immediately get in touch with the RAC and start a conversation. This conversation can start as a telephone call, but ought to be followed up immediately by a letter to the RAC, to document your call and also the discussion itself. Keep in mind, the objective would be to overturn the decision of the RAC and steer clear of each the denial and also the adjustment by the carrier/FI/MAC.
Complicated Review Discussion Period
Complex reviews are slightly various. These critiques need the RAC to look at the medical record for a claim. A RAC can (with an exception we’ll discuss in Part two) only request these records from a provider if the problem being addressed has been approved beforehand by CMS and listed – called “vulnerabilities” — on the CMS and RAC web sites. click here for rac audits, revenue cycle management, rac audits