A few nights from now, we’ll say a none-too-soon goodbye to what has been a challenging year on many fronts, but especially so (AGAIN) in the world of health care. Had it not been for a last-minute budget “deal” last week, physicians would be facing a 27%+ cut at the beginning of January. Remember that number, because it’ll make another appearance at the end of February in between invective and other Congressional nonsense.
As it applies to the subject matter of today’s blog, we have seen an almost tenfold increase in RAC activity in the past year. The RAC program, in a perfect world, would be returning money to the Medicare program that has been improperly paid. CMS has been quick to trot out preliminary results to show the success of the contractors. As a taxpayer and as someone who has been in the industry for 22 years, to paraphrase the words of Robin Williams in Awakenings, I would agree with them if they were right.
The RAC program is showing itself to be a wasteful pursuit, but like the reckless, fedora-wearing, Canadian Club-soaked shooter at the craps table at 2 AM that metaphorically defines those who direct government appropriations, CMS is all in on expanding the program to Medicaid despite facts in evidence.
I originally planned to do a review of physician issues being reviewed by the RAC contractors in this space today. As part of that process, I thought I would take a look at the RAC FAQs on the CMS website to see if there have been any glaring changes to report. Stop the presses, for did I ever find one!
In the past, the following question and answer appeared under the RAC FAQs:
“Q: I received an additional documentation request (ADR) letter from a Recovery Audit Contractor (RAC) for an issue that is not approved on their website. Do I need to submit the record?
A: RACs may request a small sample of records to assist CMS in determining if an audit concept is consistent with Medicare policy and should be approved for widespread review. Providers must still submit the requested documentation to the RAC within the expected time frame to avoid having that claim denied. The RAC will complete its review of the claim and issue a review results letter within 60 days.”
Much like Jimmy Hoffa, Amelia Earhart and the World Series hopes of the Chicago Cubs, this particular FAQ has disappeared.
On the surface, this would appear to be good news. A more reactionary reader might move to the conclusion that the RACs are no longer allowed to do reviews outside the scope of the reviewed issues lists on their respective websites. That would be a knee-jerk – and possibly costly – mistake.
For the actual answer to this question, we have to go to the revised RAC Statement of Work released back in September. I direct your attention to Page 11 under bold item #6 (why did I just get a flashback of the classic television show The Prisoner?) entitled “Random selection of claims”. According to this paragraph, the Recovery Auditors are statutorily prohibited from selecting claims randomly for review for any purpose “other than to establish an error rate”. The RACs must use data analytic techniques to conduct “targeted reviews”. I can’t speak for the reader, but the longer I look at those two sentences, I come to no other conclusion than the fact that the FAQ above disappeared has no effect on RAC operations going forward.
In order to determine that an issue should be added to an approved listing, a RAC has to first do analytics followed by establishing a reliable error rate for the issue in question. Truthfully, the only way to do that is through the type of small claims sampling used to reach a determination for widespread approval as described in the Incredible Disappearing FAQ.
The provider community is doing its level best to keep up with changes and adjustments to government audit programs. In order to keep all of our heads above water, it is in the best interests of CMS to let us know not only when new issues appear under the RAC FAQs on their website, but also to let us know when things have been redacted and why. CMS did not bother to do this in this particular case, but providers should know that as far as RAC review types are concerned, nothing has changed.