Law School
RAC 'Em Up
In the demonstration, four main reasons accounted for the overpayments identified by the RACs: a finding that the services were medically unnecessary (40 percent); incorrect coding (35 percent); insufficient documentation (8 percent); and other reasons (17 percent).
In accordance with Section 302 of the Tax Relief and Health Care Act of 2006, a permanent RAC program has been rolled out and was scheduled to be fully operational by Jan. 1, 2010.
Perhaps the biggest change implemented in the permanent program is the limit on the number of records that can be requested, which varies by provider type. Another change is that the review period has been shortened from four years to three years and, initially, the RACs will not be able to look at any claims prior to Oct. 1, 2007. Another difference is that in the demonstration, the RACs were not allowed to review claims from the current fiscal year. However, this is not a limitation in the permanent program.
During the demonstration, it was optional for the RAC to have a medical director or certified coder on staff. Both positions are mandatory in the permanent program. In the permanent program, the RACs also are required to return phone calls within 24 hours. Providers have a right to speak with the individual who reviewed their claim, and they have a right to speak with the RAC medical director.
Last, in the final program, the RAC will be required to pay back its fee if the denial is overturned at any level of the appeal.
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Jeffrey S. Baird, Esq. is chairman of the Health Care Group at Brown & Fortunato, P.C., a law firm based in Amarillo, Texas. He represents pharmacies, infusion companies, home medical equipment companies and other health care providers throughout the United States. Baird is board-certified in health law by the Texas Board of Legal Specialization. He can be reached at 806/345-6320 or jbaird@bf-law.com.
