Given my natural level of unending curiosity, I can think of no other thing as frustrating in this line of work than attending a seminar designed to relate new and important information, only to find that I have just spent good money learning well-aged facts. If I sit and think of it, this goes a long way in explaining my less-than-stellar academic career.

In past postings in this space, I have touched on the lack of useful provider outreach on the RAC program. This week, thanks to one of my contacts roaming the landscape in the land above my sealed concrete and steel bunker somewhere outside Milwaukee, Wisconsin, I received a PowerPoint presentation from CGI, the Region B RAC, that will be presented tomorrow to a meeting of health care finance professionals in my state. The slides represent further proof not only of the sporadic nature of current provider outreach, but through the use of statistics, also show that the RAC program still has a long way to go to prove the quality of its work product.

The presentation begins with RAC statistics just for the state of Wisconsin in Region B, which are quite revealing. Through the month of December just passed, CGI has completed 7,919 audits. Amazingly, only 5 of these audits have been without a finding of some type of improper payment, which on the surface appears to be a testament to the accuracy of the approved issues listing in Region B.

Of the completed audits, 502, or just over 6%, have had a discussion period requested by the provider in question. Of these claims, 258, or over 51%, have resulted in determinations of either a full reversal or findings  ”partially favorable” to the provider. These particular statistics appear to indicate that the discussion period is being under-utilized by the provider community in Wisconsin. It is worth remembering that providers can initiate a discussion up to 40 days from the date on the demand letter. Because the RACs do not directly handle claims appeals, it shouldn’t be surprising that this presentation does not contain appeal statistics.

There is one additional important bullet point in CGI’s presentation related to discussion periods. There may be some cases where due to the length of the discussion period, an adjustment request will be processed by the Medicare Administrative Carrier (MAC) prior to the issuance of a Discussion Results Letter. In these cases, if the discussion period yields a reversal, the provider will see the overpayment on a subsequent remittance advice and will receive a Demand Letter from the MAC, but the reversal will be processed and seen on a future remittance.   

There are slides in the CGI presentation that remind providers of time lines like the one in the previous paragraph above. There are 5 slides concentrating on how to best use the CGI RAC website. In checking the site, there is an update regarding the demand letter process on their front page. Other updates will have to be discovered under the Provider tab by individuals handling the RAC process for physicians and facilities.

The slides contain overviews of semi-automated review, current approved issues in Region B and the new process by which MACs issue Demand Letters. One interesting point found near the end of the presentation is related to Extended Repayment Plans. The MACs are now the point of contact for initiating such plans rather than the RACs, which is consistent with the Demand Letter change. Remember that the RACs are responsible for claims issues, and MACs cover the financial implications of those claims.

I have been critical of RAC outreach efforts in the past, but I can honestly say that there is some useful information in the slides. After reviewing the presentation in full, I do have two complaints about this process. First, it is long since past the time that the contractors update the outreach sections of their websites to reflect current and future sessions. In CGI’s case, there have been no updates to this particular schedule in 10 months. Second, while the time lines in the presentation have long been part of the RAC Statement of Work, there is increasing anecdotal evidence that there are common breakdowns in the process. Based on the volume of requests being received by some facilities, these “improvised” timelines are creating havoc even for those providers who have put a technological tracking tool in place. Many questions remain unanswered, and a few occasional PowerPoint bullets are proving insufficient to explain why.

I have sent some questions to ask of the presenter at tomorrow’s session through my contact. It is hoped that I can address my questions in a future edition of The RAConteur. Until then, from deep in the dimly-lit hallways of the compound, I bid you a temporary farewell.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.