The chiropractic Medicare Demonstration Project isn't the only project that Medicare has running. In May 2005, the Medicare Prescription Drug and Modernization Act of 2003's Section 306 Demonstration on the Use of Recovery Audit Contractors began for physicians in California, Florida, and New York. During the 3 year project, doctors will have their Medicare claims reviewed by contractors to identify over- and under-payments.
The "good" news is that this program may uncover the fact that some doctors have been underpaid, in which case the Medicare carriers will be directed to forward additional payment to the doctors. The "bad" news is that if some doctors have been overpaid, the contractor will submit a letter to the doctor asking for repayment within 30 days. As of March 1, 2006, contractors are paid based on how many under- and over-payments they identify.
RAC General Tips
- MLN (formerly Medlearn Matters) Articles SE0469, SE0565, and SE0617
- Make sure you read these articles for details on the program.
- Although this demonstration project will start out by reviewing claims from 2004 or earlier, it will go on for three years. This means that in 2006 and beyond, the RAC’s might be reviewing documentation doctors are currently working on, making the need for proper documentation all the more critical.
- If you have received a communication from one of these contractors and have questions, please call the contractor. The contact information should be on the letter you received and all the contractors are required to be open from 8:30 to 4 pm based on the time zone. Note: Your local Medicare carrier will not be able to answer questions about the RAC. The contractors are:
- When you respond to the documentation request, the contractor has 60 days to send you a letter letting you know whether they have or not identified an over- or under-payment.
- If you appeal the determination of the contractor, you have all the rights guaranteed to you under the usual Medicare appeals process. Once your appeal has been made, all recovery actions stop, including the accrual of any possible interest on a failure to repay the claim in a timely manner.
- CMS Press Release, March 28, 2005
More Resources
Q & As
Q: Is it true that the Recovery Audit Contractors (RACs) are only getting paid based on how much money they recover in overpayments? That doesn't seem fair; there's no reason for them to look for an underpayment. This just proves that Medicare is out to get providers.
A: As of March 1, 2006, RACs will be reimbursed based on how many under- and over-payments they identify. Centers for Medicare & Medicaid Services (CMS) changed the way RACs get paid based on feedback from the provider community throughout 2005 (the original design of the program only had the contractors being reimbursed for identifying over-payments,).
Q: I assume Recovery Audit Contractors (RACs) will be evaluating Drs. with assigned Medicare claims (whether the Dr. is participating or non-participating in the Medicare program), but does not effect non-participating Drs. who do not accept assignment?
A: The RAC’s purpose is to review Medicare claims, regardless of the participation status of the provider submitting them. As long as there was a claim filed, there is a possibility it could get pulled for review.
Q: If investigated for claim in 2004, will the RAC ask for records from the beginning of that occurrence, from the beginning of that year, or from the first time the patient ever entered the Drs. office?
A: The request will likely ask for data up to six months prior, or from the beginning of the occurrence. In addition, on a somewhat related note, in one of the CMS releases, the following was stated: “Claims reviewed by RACs will have been submitted to the carriers/intermediaries at least a year before to ensure that the ordinary processing will have been completed.”
Q: If patient signed an Advanced Beneficiary Notice (ABN) accepting responsibility for claims deemed “not medically necessary” by Medicare, can the Dr. retroactively recoup from the Medicare beneficiary the monies asked back from the Dr. by the RAC?
A: Yes, but only if it is a properly executed ABN. Please note: You may NOT have an ABN signed for every visit. There are strict rules for when an ABN may be signed and they must be followed or the ABN is void and the doctor can collect nothing.
Q: Can documented mobilization techniques such as Cervical Stair-Stepping and Lumbar Flexion/Distraction be appropriately billed as the 98940 Spinal Manipulation code (provided the subluxation has been well documented and associated with the symptomatology)?
A: It is the opinion of members of the ACA Coding and Reimbursement Committee that both Cervical Stair-Stepping and Flexion/Distraction do indeed qualify as a CMT procedures and can therefore be billed as such.
Q: To what specificity must our notes reflect the subluxation and manipulation; for example: Can we find and document a lumbar subluxation and manipulate the lumbar spine, or must we indicate L3/L4 subluxation and manipulation of the L3/L4 level?
A: The latter of your above scenarios is the correct method. The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. You should document each level where a subluxation exists and each level where a manipulation was rendered.
Q: On the Medicare website, the current Local Coverage Determination (LCD) presently shows the Utilization Guidelines in red. I assume that these new proposed guidelines have not been finalized (or they would be printed in black like the rest of the LCD).Does that mean that the old Utilization Guidelines are still in effect, or are these new (printed in red) guidelines presently in effect? Last year the hard-caps based on the 98940-98942 CPT codes were written in red on the LCD found on the Medicare website, but this was never instituted. When will the new guidelines go into effect or are they presently in effect?
A: First, LCDs are found on carrier web sites. Second, there are no such things as hard caps and never have been.
What you are looking at is probably the new LCD that was required to be finalized by 12-31-05. If you would send us a link to the LCD and/or Guidelines in question, we would be happy to review them for legitimacy as well as effective date.
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