ED NOTE: The recent CMS Special Open Door Forum for Part A providers conducted by CMS as an audio conference call is being reported by Ernie de los Santos in the second and final installment in two-part series. Part II: CMS describes the difference with Medical Necessity Rules and Guidelines.

Though you may consider the RACs to be like bounty hunters, the RACs are certainly NOT pirates - CMS will be holding them to the same rules that apply to current reimbursement administrators, carriers, Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs).

This was confirmed in the recent "Special Open Door Forum" conducted by CMS for Part A providers on April 8, 2009 as an audio conference call. The call included important new information, some of which was discussed in Part I. Links to a transcript of the call, as well as an audio recording of the call, also are available in Part I.

News in Several Major Topics

We want to call your attention to some new information and details that were presented in the conference call. This article discusses four topics that are important for all providers:

• A "limited number" of Complex Reviews can begin without CMS approval
• Providers are being encouraged to contact CMS project officers directly
• RAC Web sites are beginning to appear (2 of 4)
• The assurance that medical necessity guidelines, such as InterQual and Milliman, will be only guidelines for the RACs.

This last area is perhaps the most feared topic for providers, since even though the rules will be enforced by CMS, the RACs evidently will be making their own judgments about how to apply the rules when they are reviewing medical records, and specifically physician documentation.

Medical Necessity: Judgments vs. Guidelines

On the conference call, a caller asked what guidelines would be used by the RACs to determine medical necessity - a hot topic we have been writing a great deal about lately.

CMS, at least, was fairly clear in its answer to the question:

They said plainly, "...we want you to know that [those guidelines] can't be used...to pay or deny a claim."

They further stated that to judge medical necessity, RACs must abide by the same CMS policies and manuals, LCDs and NCDs, as those used now by the carriers, FIs and MACs. Nevertheless, the RACs can use whichever screening tool criteria they wish.

Frankly, this writer is not exactly sure what CMS meant by the comment that those guidelines can't be used to pay or deny a claim. What, then, is used? Their answer, though straightforward, is not very reassuring.

We had heard during a recent conference that the RACs would judge medical necessity using the same screening criteria that hospitals were using. The comments from the conference call seemed to contradict our previous understanding.

What Will RACs Use?

CMS went even further on this call. The four RAC contractors all had representatives on the line: Diversified Collections Services (DCS) for Region A; CGI Federal (CGI) for Region B; Connolly Healthcare Services (CHS) for Region C; and Health Data Insights (HDI) for Region D.