VP, Compliance and Privacy Officer

With some providers reporting that they were receiving requests for hundreds of records at once from the RACs, CMS has placed limits on the number of records that a RAC can request.

CMS, the agency that oversees the RAC program, had not intended for this administrative burden to be placed upon providers. Now, since the sky is no longer the limit, here is a summary of medical record requests for FY 2009.

Summary of Medical Record Limits (for FY 2009)

Inpatient Hospital, IRF, SNF, Hospice
10 percent of average monthly Medicare claims paid up to a maximum of 200 per 45 days.

Example 1: Local Community Hospital
1,200 Medicare paid claims in 2007
Divided by 12 = average 100 Medicare paid claims per month x
10% = 10

• Limit = 10 medical records per 45 days

Example 2: Major Medical Center
12,000 Medicare paid claims in 2007
Divided by 12 = average 1,000 Medicare paid claims per month x 10% = 100

• Limit = 100 medical records per 45 days

Other Part A Billers (Outpatient Hospital, HH)

One percent of average monthly Medicare services maximum of 200 per 45 days

Example 1:
1,500 Medicare paid services in 2007
Divided by 12 = average 125 Medicare paid services per month x 1% = 1.25

• Limit = 2 records per 45 days

Example 2:
360,000 Medicare paid services in 2007
Divided by 12 = average 30,000 Medicare paid services per month x 1% = 300

• Limit = 200 records per 45 days (capped at the maximum)

NOTE:

Some organizations may have provider numbers for both an inpatient facility and another type of facility: IRF, SNF, hospice, outpatient hospital and home health agency. In this case, the cap applies to each provider number.

Therefore, a delivery network consisting of an inpatient hospital, IRF, SNF, and outpatient hospital, for example, could receive requests for up to 800 medical records each 45-day period. This number, however, is highly unlikely due to the likely potential of lower volumes of services for the IRF and SNF.

Physicians

Solo Practitioner:
10 medical records per 45 days

Partnership of 2-5 individuals:
20 medical records per 45 days

Group of 6-15 individuals:
30 medical records per 45 days

Large Group (16+ individuals):
50 medical records per 45 days