Some healthcare providers are concerned they may not know how to proceed if their organization is audited by a Recovery Audit Contractor (RAC) and receives a payment recoupment notice. Fortunately, there is a way to learn the RAC appeal process in advance and be completely prepared.
Though the RAC program itself is new and though no contractor has yet received permission from CMS to audit a home care agency, most providers accept the fact that the day will eventually arrive. When it does, CMS has declared, the appeals process for reconsideration of a payment recoupment resulting from a RAC audit will be exactly the same as the current process for appealing a payment denial by a Regional Home Health Intermediary.
Editor’s note: We have decided to continue using the terms “Regional Home Health Intermediary” and “fiscal intermediary” for clarity. When the new name, explained below,* enters into common usage, we will begin to switch our usage as well.
CMS has made quite clear the rules under which RACs must play, including during the appeals process. The CMS Program Integrity Manual (PIM) is the guide for all contractors. Readers are invited to examine previous articles in this series for detailed descriptions of the appeals process.
From the CMS Program Integrity Manual
1.1- Overview of Program Integrity and Provider Compliance
(Rev. 313; Issued: 11-20-09; Effective/Implementation Date: 12-21-09)
Affiliated contractors (ACs) shall follow all sections of the PIM unless otherwise indicated.
Medicare administrative contractors (MACs), comprehensive error rate testing (CERT) contractors, recovery audit contractors (RACs), program safeguard contractor (PSCs) and zone program integrity contractors (ZPICs) shall follow the PIM as required by their applicable Statement of Work (SOW).
*Background on Medicare Contractors
The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to perform many functions on behalf of the Medicare program, including processing claims for Medicare payment and carrying out the first level of the Medicare claims appeals process. Historically, these companies have been known as fiscal intermediaries (FIs) for Part A services and carriers for Part B services; however, as directed by section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, both Part A and B work is being integrated under new entities called Medicare Administrative Contractors (MACs). For more information on MAC implementation, see: http://www.cms.hhs.gov/MedicareContractingReform/.
