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Key differences in nationwide rollout

The RAC Report, October 16, 2008

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Now that you know which RAC will come to your facility, it’s time to prepare for some changes. CMS revamped the program after the three-year demonstration project, and providers can expect to see the changes reflected in the nationwide permanent program.

Chief among them are:

RAC medical director.
Demonstration RACs: Not required
Permanent RACs: Mandatory

Coding experts.
Demonstration RACs: Optional
Permanent RACs: Mandatory

Credentials of reviewers provided upon request.
Demonstration RACs: Not required
Permanent RACs: Mandatory

Discussion with CMD regarding claim denials if requested.
Demonstration RACs: Not required
Permanent RACs: Mandatory

AC validation process.
Demonstration RACs: Optional
Permanent RACs: Limited

External validation process.
Demonstration RACs: Not required
Permanent RACs: Mandatory

RAC must pay back the contingency fee if the claim is overturned on appeal.
Demonstration RACs: Only required if claim is overturned on the first level of appeals
Permanent RACs: Required if claim is overturned at all levels of appeals

Maximum look back date.
Demonstration RACs: None
Permanent RACs: October 1, 2007

RACs allowed to review claims in current fiscal year.
Demonstration RACs: No
Permanent RACs: Yes

RACs solely for MSP.
Demonstration RACs: Yes
Permanent RACs: No

RAC claim status Web page.
Demonstration RACs: Not required
Permanent RACs: By January 2010

Limits on number of medical records requested.
Demonstration RACs: Optional. Each RACs set own limit
Permanent RACs: Mandatory. CMS will establish uniform limits.

Editor’s note: For more differences in the permanent program, see the next edition of The RAC Report October 30, 2008.

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