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Dig out your calculators: CMS announces RAC medical record request limitations

The RAC Report, November 13, 2008

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• Inpatient hospitals, inpatient rehabilitation facilities, skilled nursing facilities and hospices. RACs may request up to 10% of the average monthly Medicare claims (maximum of 200) every 45 days.

The CMS Web site provides the following example:

A Major Medical Center has 12,000 Medicare paid claims in 2007

• 12,000 claims divided by 12 (months in a year) = avg 1,000 paid claims/month
• 1,000 paid claims/month x 10% = 100

Therefore, the limit a RAC may request from the medical center is 100 medical records per 45 days

• Outpatient hospitals, home health and other types of Medicare Part A billers. RACs may request 1% of the average monthly Medicare services (maximum of 200) ever 45 days.

The CMS Web site provides the following example:

A provider has 360,000 Medicare paid services in 2007

• 360,000 services divided by 12 (months in a year) = avg 30,000 paid services/month
• 30,000 paid services/month x 1% = 300

However, a RAC may request a maximum of 200 medical records per 45 days because it may not request more than 200 records per 45 days.

• Physicians. The number of records a RAC may request from a physician practice depends on the size of the practice. For example, a RAC may request a maximum of 10 records from a solo practitioner, whereas it may request a maximum of 50 records from a large group of more than 16 individuals.

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