Revenue Cycle

From the field: CMS Q&A on the discussion period

Medicare Update for CAHs, April 4, 2012

After reading about another provider’s Recovery Auditor correspondence woes in a February 23 post on the Revenue Cycle Institute, Shelia Handy, RN, BSN, RAC coordinator for Lake Charles Memorial Hospital in Lake Charles Louisiana, offered her input on the matter.

Handy had emailed Connolly regarding a discussion that was submitted according to their preferred method, stating in an e-mail sent February 3, 2012:

“I submitted a discussion letter on January 12, 2012 for claim # XXXXXX via fax. I submitted timely to prevent recoupment of money within the CMS stated timeframe for recoupment. Is it possible to get a response on the discussion letter submission?”

Connolly returned correspondence, stating:

“The auditor has 30 days, per CMS, to respond to the discussion request.  However, we suggest beginning your appeal process once you receive the demand letter rather than file a discussion with Connolly.  The time frame for recoupments and appeals with your payer begins once you receive the demand letter.”

Since she did not receive a decision from Connolly regarding the discussion period, Handy decided to voice her concerns to Amy Cinquegrani, who works for the Division of Recovery Audit Operations at CMS.

Cinquegrani responded promptly, and offered Handy some guidance, stating:

If you are referring to strictly automated reviews, than it is possible to have a discussion period, but there are times when it may be best to just appeal.  Because of the nature of the automated review, providers are not aware of the review until they receive a demand letter.  At that point, the claim has already been set up for adjustment.  Per their statement of work, Recovery Auditors have 30 days to respond to a discussion. 

It is very possible that by the time you initiate your discussion, and the Recovery Auditor has responded to the discussion, your automated claims have already been recouped if the 41 days has passed.  Also please note that there is not a specified timeframe in which to initiate a discussion period, and a discussion is not the same thing as a rebuttal.  For more information on the options afforded to providers when receiving notification of a RAC overpayment, please see the provider options chart at:  http://www.cms.gov/Recovery-Audit-Program/Downloads/ProviderOptionsChart.pdf

Although it still is possible for Connolly to review your documentation and determine if there really wasn’t an improper payment, at that point (since your claim is already set up for adjustment), they will need to work with the claims processing contractors/MACs to reverse the adjustment.  This may involve letting the recoupment happen, and then waiting for the money to be refunded back.

For the most part the discussion period was meant for complex reviews, where the provider receives notice of the improper payment first through the review results letter.  At this point, the claim has not been set up for adjustment at the MAC, and discussion may be able to take place before that happens.  They still have 30 days per their SOW to respond to the discussion request, however. 

If you are finding that there is an overall problem with Connolly’s automated review approach, (as in, claims are being inappropriately targeted for review, they are misinterpreting policy, etc, and not just an isolated issue with one or two claims), this would be best brought to both CMS’ and Connolly’s attention outside of the discussion.  That way CMS can intervene on an inappropriate audit. 

Editor’s notes:

For information on the difference between a discussion and a rebuttal, click here.

These “Share your RAC story” submissions are intended to show other providers out there that these things are happening everywhere. But they are also intended to create conversation and connect like-minded individuals. Have you been experiencing any type of problems with recovery auditors lately at your facility? Would you like to offer advice to this reader by sharing your experience? If you do, then click here to comment. If you have ideas, questions, or concerns of your own, submit them to jcarroll@hcpro.com.

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