April 8, 2009

RAC Requests for Medical Records - There are Limits

By
Cheryl ServaisBy Cheryl E. Servais, MPH, RHIA

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

 


Other Part B Billers (DME, Lab)

One percent of average monthly Medicare paid services per 45 days up to a maximum of 200 medical records 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)

 

By the Numbers

There are eight 45-day periods in a year. Therefore, a provider must multiply its 45-day limit by 8 to determine the number of records that a RAC could review in a one-year period. At the maximum level, a RAC could review 1,600 medical records per year.
 

At any point in time, a provider will have medical records/claims involved in each of the various RAC review phases:
 

• Providing medical record copies
• Waiting for the results of RAC review
• Researching and writing a Rebuttal letter
• Researching and submitting a Level One appeal
• Other appeal levels


The provider needs a robust tracking mechanism in order to follow a medical record and the accompanying claim from the initial provision of information to the RAC through any appeal processes undertaken.


The tracking mechanism should also allow the provider to analyze the results of the RAC process:

 

• Number and % of claims with no change
• Number and % of claims with overpayment findings
• Number and % of claims with underpayment findings
• Reasons for overpayments and underpayments (MS-DRG, APC, Code, Medical Necessity, Type of Service, etc)
• Number and % of rebuttal letters files and results
• Number and % of appeals files and results
• Dollar impact of overpayments and underpayments


Tracking

Starting the RAC audit cycle with a good tracking program will provide invaluable support for tracking and analyzing this new process.


About the Author

Cheryl Servais has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais' responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the Executive and Board levels; and takes an active role in professional organizations.

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Cheryl E. Servais, MPH, RHIA, is Vice President, Compliance and Privacy Officer for Precyse Solutions

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Cheryl E. Servais, MPH, RHIA

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