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RACMON:  If you’re on the new HDI Web site and you’re seeing what appear to be contradictions to what you’ve previously thought you understood what’s going on? What have you found, Dennis?

DENNIS: This is from HDI RAC Questions section:

    How far back can HDI go in reviewing claims?

    RACs can review back three years from the Date of Service or a Date of Service of October 1, 2007, whichever is earlier.

DENNIS:  CMS and the other three RACs have been consistently saying, Claims adjudicated as of 10/1/07.”  This is the first time I have seen “Dates of services as of 10/1/07.” Would that be Admit Date or Discharge Date? Do you think this is a typo?

CHERYL:  Well the issues’ section of the HDI site states, “claims paid on or after October 1, 2007.” Here is the verbiage from the Statement of Work – clearly stating FY 2008 claims:

    The RAC program will begin with claims paid on or after October 1, 2007. This begin date will be for all states. The actual start date for a RAC in a state will not change this date. As time passes, the RAC may look back 3 years but the claim paid date may never be earlier than October 1, 2007. In other words the RAC will only look at FY 2008 claims and forward. The RAC will not review claims prior to FY 2008 claim paid dates.

CHERYL: The service date would be cleaner because the rules for IP billing/payment/coding change on Oct 1.  I thought the whole point of the Oct 1 parameter was to keep the RAC from having to deal with DRGs and MS-DRGs and the charge/cost reimbursement issues.  If it were a claim with a service date of Oct 1 or later, the Admission date would be the one used.

DENNIS: Hmmm.  That SOW statement seems concise and consistent with what I’ve been hearing up until now. And I have always thought that this was one of the great complications of the RAC: the fact that there would be two different groupers.

LINDA: With respect to the RAC program, I think the language of the SOW should control for now.  However, when it comes to look back dates, the RAC SOW is cold comfort since other CMS contractors (i.e., the ZPICs) are not limited by that date.

DENNIS:  OK, and how about this one:

    “Hospitals and other providers under a Medicare cost reimbursement system receive no photocopying reimbursement. Capitation providers, such as HMOs and dialysis facilities, wil receive $.12 per page. Non-PPS acute care providers will receive $.15 per page.”

DENNIS: Did I miss something?  I never heard of hospitals being excluded from the $.12 per page reimbursement for copies.

CHERYL: Again, I went to the statement of work

    RACs are required to pay for copying of the inpatient (PPS) and Long Term Care hospital medical records on at least a monthly basis. For example, a RAC may choose to issue checks on the 10th of the month for all medical records received the previous month. All checks should be issued within 45 days of receiving the medical record.

CHERYL: On the FAQ – there is this answer:

    RACs are required to reimburse PPS providers and Long Term Care providers. The reimbursement rate is 12 cents per page for reproduction of medical records. Facilities are not required to submit vouchers to the RAC requesting payment. Rather, the RACs will automatically issue payments to the hospitals for photocopying charges. RACs are required to pay for copying on a monthly basis. All checks should be issued within 45 days of receiving the medical record.

DENNIS: OK, I called HDI. They say that the “Date of Service” is a misprint. The passage should read, “Date of Payment.”

Also, they want the medical records reimbursement section to clearly state that, “acute care PPS hospitals and LTCs will be reimbursed $.12 per page but that Critical Access Hospitals under a Medicare cost reimbursement system receive no photocopying reimbursement.”

DENNIS: I didn’t know about CAHs being excluded.

LINDA: It is not at all surprising to find discrepancies in CMS/Medicare “rules,” and in materials that interpret the “rules.”  After all, there are thousands upon thousands of pages of laws, bulletins, manuals, LCD’s, etc. that pertain to the administration and enforcement of the Medicare program.  In researching any issue, we often find conflict within these materials.  It is then up to the skill of the attorney, or individual presenting the case, to determine the pertinent and controlling “rule,” and to convince the powers that be of your interpretation.

NANCY:  This is a great discussion and it points to not only the inconsistencies we have seen in RAC communications, but also our challenges in writing articles and providing “opinions” for RACMonitor (not to mention consulting with clients!). It really stresses not only the important of citing sources but also citing conflicting sources.

DENNIS:  I was told that there would probably not be corrections/clarifications “until the HDI executives returned from Outreach Training.”

RACMON:  Thank you all for taking time to help clear up some of these questions.

For more information on this developing story, be sure to bookmark www.racmonitor.com.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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