The RACs have not yet begun targeting hospices and may not until 2010. Why should hospices worry about them? No one knows at this point how intense the RAC scrutiny of hospices will be. Could all this RAC concern be a case of much ado about nothing?
Maybe, but probably not. Let’s look at some of the things we know and some of the concerns:
RACs are not a myth.
Four regions have been designated and RAC contracts for each region have been awarded. The Tax Relief and Health Care Act of 2006 made the RAC program permanent and expanded it to all 50 states by January 10, 2010. The RACs are mandated to review paid claims for all Medicare Part A and B providers – this includes hospices.
RACs are paid on a contingency basis
Unlike other Medicare contractors, RACs are paid a percentage (9.0% to 12.5%) of money recovered for Medicare. Given this unique payment structure, there is legitimate concern the RACs might be more aggressive in their scrutiny than what we have seen before – they may be somewhat similar to bounty hunters.
In their eagerness to recoup money RACs might “overreach” even more than RHHIs
Prognostication never has and never will be an exact science. We have seen with ADRs how the RHHI’s have “overreached” in some of their denial determinations. The tools and guidelines available for assessing eligibility for hospice care are inherently limited. Hospices have a responsibility, through comprehensive and accurate documentation to make a strong case for each patient’s eligibility. But even with good documentation, we have heard that claims have been denied because “the patient’s needs were met by the facility,” or “there was no acute event to precipitate the patient’s admission to hospice.” With the RACs being incentivized to recoup money, will they be likely to find even more spurious reasons for denial of claims? RACs are required to follow Medicare policies, LCD guidelines etc. They are not allowed to make their own policy – but neither are the RHHIs.
What training in hospice will RAC reviewers have?
We have seen how clinical record reviewers for RHHI’s are often poorly trained regarding hospice regulations, LCD guidelines etc. Given that the RACs are so hospital focused, how can we be certain their reviewers will understand hospice, the challenges of prognostication and the nuances of the Medicare hospice benefit?
RHHI/MAC denials + RAC denials = Cash flow disaster
Many hospices across the country are burdened with heavy ADR/TMR activity and navigating the maze of the Medicare appeals process. The scrutiny of both pre-pay and post-pay claims by the RHHI’s/MACs is not going to subside when the RACs are fully functional. Although RACs and MACs are not allowed to review the same claims, there are likely enough claims out there to keep both of them busy and hospices burdened. Paying money back to Medicare for care that has already been provided or not getting paid for care provided will significantly impact a hospice’s cash flow. Having reimbursement tied up in the lengthy Medicare appeals maze could threaten a hospice’s financial viability.
RHHI/MAC denials + RAC denials = Medical records department nightmares
RACs are allowed to review 10% of a hospice’s average monthly claims every 45 days. There is no limit placed on the number of claims RHHI’s can review. Making certain that medical records that are requested for review are copied and sent in accordance with stringent deadlines will require careful tracking and monitoring and will be labor intensive.
The Medicare appeals process is lengthy, expensive and complicated
Navigating the Medicare appeals process can be challenging, labor intensive and expensive. Given that most appeals are denied at the first two levels and not overturned until the ALJ level of appeal, it is a long road from first appeal to the ALJ level. The good news here is that hospices can halt the recoupment process for the first two levels of appeal. However, if they are not successful (and probably will not be), the overpayment will be recovered when the second level of appeal is denied. Keeping track of each stage of the appeals process for claims from both RACs and RHHIs/MACs will require consistent monitoring and attention.
These are probably enough worries for the weary for one day. RAC Assistance for Hospice will be addressing these worries in more depth in the weeks and months ahead with the hope of offering strategies for dealing with some of the challenges outlined above.
