Commander Marie Casey, deputy director of CMS's Audit Division, spoke frankly and directly with RAC about concerns that had been expressed by many providers after reports were published regarding remarks made at provider outreach sessions concerning when, what or even if physician providers were going to be audited by RACs during the permanent program.
Present on the CMS call were: Connie Leonard, director of the CMS Division of Recovery Audit Operations; Commander Marie Casey, deputy director of the division; Howard Coan of the CMS Press Office; Chuck Buck, President/CEO of RAC Monitor; Patricia Dear, RAC Monitor Editorial Advisory Board and president/CEO of eduTrax; and Ernie de los Santos, RAC Monitor Contributing Editor and vice president of technology for eduTrax.
National Provider Identifier (NPI) Background
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.
As outlined in federal regulation contained in, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.
RAC Medical Record Requests and NPI Numbers
As a part of the interview with Casey the following question was asked and answered:
Question: The number of medical records which can be requested by RACs is up to a maximum of 200 per NPI for inpatient, and for outpatient services also a maximum of up to 200 records per NPI every 45 days. What if the provider has one NPI for both inpatient and outpatient services - would that be 200 for inpatient & outpatient combined, for a maximum total of 200, or 200 for inpatient plus 200 for outpatient for a total of 400 under the one NPI?
Answer: As of now and "on the record," it is a maximum 200 records per NPI. However, where a hospital provider may have more than one NPI, but have only one (shared) medical records department for the organization (or campus), the maximum would still be 200 every 45 days.
Follow-up Question: So where a hospital provider provides multiple outpatient services, inpatient services, has an acute inpatient rehabilitation program (IRF), each with different NPI numbers, would the total be 200 per service category or 200 for the total hospital?
Answer: No, it would be 200 for the total.
Follow-up Question: Where is this information posted?
Answer: We are purposefully holding off posting that information until the fall, as we are trying to focus on getting the RACs up to speed with the process and the beginning of the "automated" recoupments, adjustments that will start this month (August).
As I stated in Part I of the interview posted last month, the conversation with Casey was insightful and open, and it brought clarity to previously misunderstood information. That said, however, while monitoring the CMS RAC question and answer, which can be found on the CMS Web site, a few interesting and relevant questions were posted and answered as reproduced below. However, no specific information has been posted as of the date of this article regarding NPI and record maximum limits - stay tuned on that issue.
On Sept. 25, 2009, a question and answer (Q&A) was posted on the CMS RAC Web site regarding medical record request limits, which follows in its entirety:
"Question: I heard that RAC medical record request limits will be based on my 2007 claims volume, then I heard on 2008. Which is it?
Answer: We apologize for the confusion. Limits in the remainder of the fiscal year ending September 30, 2009, are based on claim volume in the 2008 calendar year. This differs from our original announcement that limits in the current year would be based on 2007 claim volumes.
Our original plan was to use the previous calendar year's volume to calculate the following fiscal year's limits. In other words, we envisioned using claims paid from January 2007 through December 2007 to develop limits for October 2008 through September 2009. Claims paid in calendar 2008 would then drive limits in fiscal 2009, calendar 2009 would drive fiscal 2010, and so on.
Unfortunately, the RAC program was subject to a several month delay while various contract issues were being resolved. By the time we were ready to resume work in February 2009, claim data for all of 2008 was available. Recognizing that many providers have grown or contracted due to changes in the economic environment, we decided to use the most current figures available to us instead.
We recognize that the calendar/fiscal year schedule is confusing and were exploring other alternatives for future years. We welcome suggestions at firstname.lastname@example.org."
Some other interesting and topically similar questions also were answered and posted on the site:
12/02/08 Posted Question: If I receive a demand letter from a Recovery Audit Contractor (RAC) because a service didn't meet Medicare's medical necessity criteria for an inpatient level of service, can we re-bill all the services on an outpatient claim?
Answer: Providers can re-bill for Inpatient Part B services, also known as ancillary services, but only for the services on the list in the Benefit Policy Manual. That list can be found in Ch. 6, Section 10: http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf. Rebilling for any service will only be allowed if all claim processing rules and claim timeliness rules are met. There are no exceptions to the rules in the national program. The time limit for re-billing claims is 15-27 months from the date of service. These normal timely filing rules can be found in the Claims Processing Manual, Chapter 1, Section 70: http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
7/23/09 Posted Question: If a provider performs a self-audit, how should they notify the Recovery Audit Contractor (RAC)?
Answer: If a provider does a self-audit and identifies improper payments, the provider should report the improper payments to the appropriate Medicare claims processing contractor. The exact information necessary for the self-referral can be determined by contacting your local carrier, FI or MAC (your claim processing contractor). There are two types of self audits. One is commonly called a voluntary refund and is claim based. If the required claim information is included along with the amount of the improper payment, the claim will be adjusted by the claim processing contractor. The RAC will be aware of the adjustment, but the refund does not preclude future review. The second type of self-audit may involve the use of extrapolation. If extrapolation is used, the claim processing contractor will review the case file to determine if it is acceptable. The claim processing contractor will accept or deny the extrapolation for the issue identified by the provider. If the claim processing contractor accepts the extrapolation, those claims in the universe will be excluded from RAC review.
8/26/09 Posted Question: If a provider has performed a self-audit prior to RAC review and wants to extrapolate these findings, will all these claims included in a self-audit be excluded from RAC review?
Answer: If a provider self-discloses a payment error and the Claims Processing Contractor confirms that a payment error exists and the sampling/extrapolation methodology used was correct, then these claims will not be reviewed by the RAC. The claims processing contractor will exclude the self-disclosed claims in the RAC data warehouse.
9/30/09 Posted Question: If I am a chain provider whose FI is WPS (serving as the national fiscal intermediary) who will my Recovery Audit Contractor (RAC) be?
Answer: This answer assumes the hospital originally had Mutual of Omaha as the claims processing contractor and the merger of WPS and Mutual of Omaha is how WPS became the provider's claim processing contractor. WPS currently serves as a national fiscal intermediary in CMS. They service providers in the majority of the states. These providers have not yet transitioned to a MAC. WPS will work with all 4 RACs. If WPS is your claim processing contractor, as the national fiscal intermediary and not part of the local jurisdiction, your RAC is based on your physical location. For example, if you are located in Tennessee, but WPS is your claims processing contractor, your RAC is in Region C.
As I stated in Part I of the interview posted last month, the conversation with Casey was insightful and open, and it brought clarity to previously misunderstood information. Hospital providers and staff MUST remain abreast of the continuing RAC program "tweaks," which will occur over time.