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RAC Implication


Section 525 of the Act entitled, “Clarification of 3-Day Payment Window,” leaves one RAC issue somewhat murky.  Since the Act prohibits The Secretary of Health and Human Services to  “reopen a claim, adjust a claim, or make a payment pursuant to any request for payment under title XVIII of the Social Security Act, submitted by an entity…” there is some discussion that this might not only prevent hospitals from unbundling services and rebilling distinct outpatient bills, but it might also ban RACs from recouping improper payments for wrongfully bundled serves as well.


That’s not how I read it, however, we will all be anxious to see how the enforcing regulations are worded before we can be sure.  Meanwhile, Sen. Reid has indicated that there are other issues covered in this act that may be hotly debated, and if significant changes are made to the House version, the bill must go back to the House for reconciliation.


This will give providers who have made the decision to take the plunge and unbundle, recode, and rebill the hundreds or even thousands of affected claims a little more time to submit those claims before the window slams shut.



About the Author


Dennis Jones is the director of compliance services for CBIZ KA Consulting. While Dennis is recognized as a leading RAC issues expert, his expertise covers a wide variety of topics including Managed Care, Uncompensated Care, Medicare and Medicaid Compliance, HIPAA, and Process Improvement. As a result he has spoken previously for NJHA, World Research Group, and various state chapters of HFMA, AAHAM, and AHIMA. Dennis is a past-president of the New Jersey Chapter of AAHAM and has held senior management positions in provider, IT vendor and reimbursement consultant arenas. He is a graduate of the Pennsylvania State University with a degree in Health Planning and Administration and hopes to be able to afford season football tickets some day.


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