Author Topic: RAC Audits (Automated Demands and requests)  (Read 1589 times)

dfranklin

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RAC Audits (Automated Demands and requests)
« on: November 30, 2010, 05:52:04 AM »
Has anyone had their practice recieve an ADR from CMS?  One of my providers received an ADR (I guess it stands for additional documentation request) received from HighMark Medicare I presume that is an automated RAC request, is that correct?  There is no mention on the letter about DCS or RAC Contractor anywhere so I am not sure if this is from a RAC contractor or not.  It looks just like a letter from CMS stating this is an ADR and the address to mail back to is just Highmark CMS’s regular address, not a RAC contractor address. How do you handle those? Put them back on the provider or do you help with those? Most billers tell the providers we will do appeals for them but what do we do about these?


Does anyone have a way for us or the provider to handle the tracking and managment of these RAC demands and requests that come in?  When they were responded to, status, responses back, appeals etc.  As these start to roll in more and more there could be many in process at one time and keeping organized and tracking them could become a major task in itself.  Anyone have ideas?

PMRNC

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Re: RAC Audits (Automated Demands and requests)
« Reply #1 on: December 04, 2010, 09:41:46 AM »
Don, in my compliance program I address RAC's and my first plan of attack is to consult with the provider about getting third party to do handle them..that's for integrity purposes..BUT what you have does not sound like a RAC request, those will usually state that's what it is.

It sounds like you COULD have a red-flag out there for something ... but you don't mention..is it one or two patients..is it for a batch of claims.. is there a common denominator?
Linda Walker
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dfranklin

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Re: RAC Audits (Automated Demands and requests)
« Reply #2 on: December 05, 2010, 08:49:47 PM »
What compliance program?  Something on your website?  Or something you are just offering your providers?

I think it is a red flag as well the only common denominator seems to be the codes from 98940 to 98943.  Different patients an different submissions, batches etc.

I also just found out that a different carrier (Highmark BCBS) is currently auditing them for over 100 patients (this is their biggest carrier) and they have been doing everything on their own and I just got wind of it.  Not sure of any of the details etc just that they have been busy handling it.  Not sure what I could do to help them...

Maybe the carriers are talking to one another?  Because Highmark is their Bcbs and Medicare for PA is also Highmark???

Where can I find out how to put together  compliance plans?

Michele

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Re: RAC Audits (Automated Demands and requests)
« Reply #3 on: December 06, 2010, 07:37:29 AM »
I don't know if this has anything to do with it but Medicare for NYS & CT have a pre-edit audit for all 98940 - 98941.  This is generating a request for notes for any claims with these codes.  This is the result of audits on a few select providers where it was determined that those codes were being billed inappropriately 89% of the time.  Maybe there is something similar happening in your area?  ???
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oneround

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Re: RAC Audits (Automated Demands and requests)
« Reply #4 on: December 06, 2010, 05:30:57 PM »
D.  ADR's are nothing new I have seen these over and over again here in Southern Cal. and for various medical services.  Most recently I have been auditing EPO injections and many of the charts I have reviewed there had been ADR's on file.  It's a Medicare Internal Audit in which they are reviewing and requesting additional information.  This is not a RAC audit.  Michele gave a good point, these are usually pre-edit audits for specific CPT codes as in the ones I have reviewed for Epo J and Q codes.
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

PMRNC

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Re: RAC Audits (Automated Demands and requests)
« Reply #5 on: December 06, 2010, 09:23:19 PM »
Quote
What compliance program?  Something on your website?  Or something you are just offering your providers?

Meaning the compliance plan I have in place for my business. All billing company's should have one. It's your road map which tells you what to do, mine of course is taylored for my business but based on recommendations by OIG.

The word "AUDIT" whether referring to RAC's or not.. is something to take very seriously. I would simply call the carrier(s) and just ask them. Did they send a letter?
Linda Walker
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DMK

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Re: RAC Audits (Automated Demands and requests)
« Reply #6 on: December 07, 2010, 10:56:12 AM »
Last July all Northern California Chiropractors had approximately 50% of their claims audited.  Now I usually get 1 per claim batch.  The ADR is easy to fill out, and I can only offer my personal experience.

Send transcribed Tx notes (handwritten ones seem to get denied stating they were "illegible"), be sure the doctor SIGNS the notes.  Send any reports you have to verify the diagnosis.

I get 90% of my audited claims paid.  The ones they don't pay I usually figure out what I did wrong, or what was missing.

Good luck!