Tuesday, March 4, 2014

Questions to CMS on Impact of the RAC ‘Pause’

Dan Ciolek

Since CMS announced (2/18/2014) a ‘pause’ in Recovery Auditor pre- and post-payment review activities on its web page,  AHCA and the National Association for the Support of Long Term Care (NASL) sent CMS questions asking for clarifications.  The questions, divided into topics for those interested in specific areas of inquiry, follow. We will report on CMS’s responses as soon as we hear back from them.

  1. Question related to applicability of the RAC ‘pause’ to Part B therapy MMR:
    a. Does the RAC ‘pause’ apply to Medicare Part B therapy MMR? (*CMS answered this one, see below for the response.)

  2. Questions related to claims processing and medical review during the ‘pause’:
    a. Does the ‘pause’ affect the $1,920 therapy cap and exceptions process policy?
    b. Will Part B therapy clean claims above the $3,700 MMR threshold (e.g. those passing system edits), including those in the 11 pre-pay MMR states, be paid timely during the ‘pause’?
    c. While the RAC $3,700 MMR reviews are ‘paused’, what instructions are MACs being provided by CMS regarding how to handle these claims?
    d. Will the MACs be providing any instructions regarding the ‘pause’ to providers?
    e. While the RAC $3,700 MMR reviews are ‘paused’, will MACs be performing any manual medical review on claims above $3,700?  And if so, how will providers be able to differentiate whether an ADR is a legitimate MAC ADR versus an erroneous MMR ADR?
    f. What actions should the provider take should they receive apparent erroneous Part B therapy MMR ADRs during the ‘pause’ that appear to have letter generation dates after February 21, 2014 for post-payment review, or after February 28, 2014 for pre-payment review?
  3. Questions related to the end of the ‘pause’:
    a. When will the RAC Part B therapy MMR ADR ‘pause’ end?
    b. Does the ‘pause’ mean that claims in pre-pay MMR states not reviewed during the ‘pause’ will be subject to post-pay MMR once the ‘pause’ is ended?
    c. We are concerned that if CMS attempts to issue post-pay ADRs for all claims above the $3,700 threshold that were processed during the ‘pause’ once the ‘pause’ is over to catch-up on claims missed during the ‘pause’, providers and contractors will be overwhelmed by the immediate administrative burden related to the backlog that will develop during the ‘pause’.  Will all Part B therapy claims above the $3,700 MMR threshold during the ‘pause’ be subject to post-pay MMR review once the ‘pause’ is ended, or is CMS considering alternatives to prevent this undesirable situation?
    d. Will the Part B therapy MMR reviews be conducted by RACs or MACs once the ‘pause’ is ended?
    e. Will the Part B therapy MMR reviews resume the current pre- and post-pay model once the ‘pause’ is ended?
  4. Questions related to beneficiaries: a. During the ‘pause’, may providers issue voluntary Advance Beneficiary Notices (ABNs) to beneficiaries if they determine that Medicare is unlikely to cover the services over $3,700 once the MMR reviews resume?
    b. Will CMS inform beneficiaries of the RAC ‘pause’ for Part B therapy services above the $3,700 threshold?
    c. Will providers be furnished materials and/or standardized language (e.g. MLN products) that they can provide to beneficiaries to inform them of the RAC ‘pause’ for Part B therapy services above the $3,700 threshold?
  5. Questions related to MAC/RAC activities on existing MMR ADRs in progress during the ‘pause’:
    a. Will there be a means for providers to verify receipt of the record and status of the claim during the MMR process?
    b. How will Providers verify that the MMR process has been completed and know the results at the 10 day point?
    c. How will MACs ensure that they process the RAC findings timely to either pay the claim or issue the denial?
  6. Questions related to Congressional action/inaction:a. What will happen if Congress fails to extend the exception process for the Therapy Caps by April 1, 2014?
    b. If the exception process expires and patients reach the therapy cap, will beneficiaries have any rights to appeal?

*Answer for #1 above:
Does the RAC ‘pause’ apply to Medicare Part B therapy MMR? On 2/20/14 CMS provided the following initial response:
Yes, the upcoming RAC pause includes the Part B therapy MMR.  We are hoping to clarify this on the website early next week. 

February 21, 2014 is the last day for Recovery Auditors to send ADR letters (complex reviews and semi-automated reviews). This date also applies to post-payment reviews of Outpatient Therapy claims over the $3700 Threshold. 

February 28, 2014 is the last day for MACs to send ADR letters for the Recovery Auditor Prepayment Demonstration (complex reviews). This date also applies to prepayment reviews of Outpatient Therapy claims over the $3700 Threshold.

If a provider has already received an ADR letter, or will receive one of the last ones (sent by the end of this month), the provider must comply with the request and submit the records, or a denial will be made on the involved claim(s).

Any records that were previously submitted to the Recovery Auditor will continue to be reviewed, and the provider will receive a review results letter, as usual.

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