March 3, 2010

A Rebuttal on RAC Rebuttals

By

huntMLittle did I know when I e-mailed one of the authors of a Feb. 3 article in RACMonitor (Is It Worth the Effort to Rebut RAC Findings:  10 Steps for a RAC Discussion) that my comment would turn into a discussion and now an article of my own on the differences between the discussion and rebuttal processes.


It seems that for some contractors, there may be some gray areas here; for RACB- CGI, there is not. RACMonitor asked me to explain the differences, as I understand them, from an e-mail discussion with CGI.


For those of us in RAC B, discussion and rebuttal are distinctly separate, directed at different entities and featuring their own different time frames. It was after the September 2009 rollout meeting in Ohio that I got the impression that the two terms were distinct. When I asked CGI to clarify the differences so that I might work with my facilities on addressing them, however, they responded by saying that there was confusion surrounding the rebuttal versus the discussion period due to the fact that the two terms had become synonymous during the RAC demonstration period:


"For the national program, the term ‘rebuttal' is correctly used to indicate the process by which the provider can request the FI, Carrier, or MAC to review the recoupment amount. Primarily, rebuttal is used to discuss or debate the provider's ability to fulfill an overpayment, or a dispute on the portion that is owed to the Medicare contractor. The RAC ‘discussion period' allows the provider the opportunity to discuss the medical facts of the case with the RAC, and so the discussion period is distinct from the rebuttal period. For the discussion period, providers are encouraged to contact the RAC immediately if they disagree with a RAC determination." (12/9/09, 12:33 p.m., by e-mail)


The Rebuttal

 

Per Medicare regulations, the rebuttal requires the FI or MAC to  "give the provider or supplier an opportunity, before the suspension, offset or recoupment takes effect, to submit any statement (to include any pertinent information) as to why it should not be put into effect on the date specified in the notice." (42 CFR 405.374)  I followed up to CGI with a query on timing of the rebuttal process and was told that this is the step with a 15-day turnaround.


The Discussion


The discussion process, on the other hand, is directed at the RACs themselves and is all about the denial details - mainly the clinical or coding details - and why the provider thinks a denial should be overturned.


If a demand or review results letter indicates a shortcoming in the medical record, a review focusing on that shortcoming is in order. If the shortcoming is a simple error - a level of care (LOC) order obviously missed during RAC review, a statement in a physician's note backing up a CC/MCC assignment, even a piece of documentation missed in the first ADR (Additional Documentation Request) that can be faxed to the RAC for consideration (say, a coder's query) - then contact with the RAC is in order. Simple medical necessity denials can be addressed during this period as well, but this mainly is going to be done by fax, with additional documents sent for review of reasonable and necessary medical care. Involving the quality department medical director or physician champion also may be necessary. The discussion can lead to a complete or partial reversal of the denial.

 

The Important Difference

 

While the distinction between rebuttal and discussion seems minor, operationally the difference is important in that it increases the options providers have to get a denial reversed.

 

During the rebuttal and/or discussion period we are not letting appeal time tick by - behind the scenes, we are exploring appeal merit and beginning to put together what we will need to build a Level 1 appeal in case the discussion does not reverse, or only partially reverses, the denial. All three processes, rebuttal, discussion, and appeal, are begun concurrently and ALL can be attempted if sufficient merit is present.

 

The three time clocks tied to each process start on the date the first letter is received (the review result letter for complex reviews or the demand letter for automated reviews). The provider then has until day 15 to rebut to the FI, carrier or MAC; until day 40 to discuss with CGI; and until day 120 to file an appeal (unless one wishes to stop the recoupment process, in which case an appeal should be filed by day 30).

 

I suggest you check with your own region's RAC to find out whether it treats the discussion/rebuttal as one process or two, and use that knowledge as you lay out your RAC review timelines.



 About the Author

 
Maureen Hunt, RN, MHSA, is Government Audit Consultant for the Health Alliance of Greater Cincinnati. Having worked for 15 years in multiple areas, and in roles from staff to Director in the clinical provider side, she moved to Quality Management and then into Utilization as she worked on process revisions to improve denials management. As the RAC programs advanced, she began focusing on Government payers and moved to specialize in Gov't Audit processes.


Contact the Author

Maureen.Hunt@healthall.com

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