Updated on: June 22, 2012

Rapping with Your RAC: Introducing the Discussion

By
Original story posted on: March 2, 2010

cengle120xNow that the RAC audits are in full swing, providers may be wrestling to understand the new discussion period and the implications for choosing to exercise this new option and when they should actually consider initiating a discussion period. 

The discussion period is new to the permanent RAC program and has some major differences from the "rebuttal period" of the demonstration project.  During the demonstration project the rebuttal was actually part of the appeal process and was used only to discuss mathematical errors with the RAC. Now CMS has given providers this new opportunity to dialogue with their RAC about many more issues and has actually made it a separate process altogether that is potentially more favorable to the provider.


What is the discussion period?


CMS called it the "rebuttal period" in the demonstration, but in the permanent program it is being called the "discussion period." During this informal and voluntary phase that is not a prerequisite to the appeal process, you can identify your grounds for a dispute ("I think you're wrong, and I have more information to support that") and dispute alleged overpayments. In an open-door forum call, CMS stated that you literally may pick up the phone with your RAC auditor and initiate the discussion period, but also suggested that you send a follow-up letter with supporting documentation.  Check with your own RAC auditor to see what its requirements are in documenting the discussion period; at the end of the article we point out some differences in the RAC Web sites and how they handle the discussion period. At least one of the auditors (DCS) has a form letter that needs to be filled out and submitted to initiate a discussion period.

 

What are the time frames for the discussion?

 

In September 2009, CMS clarified in a posted "Frequently Asked Question" about when exactly the "discussion period" occurs, which had been a source of much confusion for providers because it is not a part of the Medicare appeals process or the demonstration project.


CMS explains that the discussion period begins when the provider receives the notification of RAC review results (for complex reviews) and when the provider receives the demand letter for automated reviews. CMS also explains that the discussion period lasts until the issue is resolved or when the recoupment is complete.  As CMS also points out, however, the discussion period does not extend the provider's appeal timeframes. CMS further clarifies that the discussion period normally requires written notification to the RAC.

 

Although the discussion period may continue beyond the issuance of a demand letter, providers that choose to enter into a discussion with a RAC need to be careful not to put all their eggs in one basket for the discussion because the clock starts ticking for submitting the first level appeal to the Medicare Administrative Contractor (MAC) as of the date of the demand letter.

 

The discussion period has two different initiation times, depending on whether it is for an automated or complex review. With an automated review, the discussion period starts with the receipt of the demand letter from the RAC.  For a complex review, however, the discussion period begins when the provider receives the review results letter that arrives before the demand letter, actually giving the provider additional time to discuss the denial with the RAC. The discussion period ends upon recoupment of the money (i.e., Day 41) regardless of the type of review.

 

"The determination process for the RAC has not changed," according to Connie Leonard, director of the Division of Recovery Audit Contracting for CMS/OFM. "There has been a lot of confusion surrounding the discussion period and we are attempting to provide clarification to providers. The term, "review results" is often used now in place of "determination," as "review results" just are simpler to understand. It is still a determination of the review (an underpayment, overpayment or no finding)."


For an automated claim review


The provider will be issued only a demand letter; there is no review results letter. The discussion period is from Day 1 (from the date of the demand letter) through Day 41.

 

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For a complex claim review:


In a complex review, where medical records and/or additional documentation are requested and reviewed, the provider always will receive written notification of the outcome of the review - commonly called the review results letter. This is sent to the provider within 60 days of the RAC receiving records from it. The discussion period begins with the provider receiving the review results letter and does not end until recoupment would begin (41 days after the provider receives the demand letter). At this time the review results letter and the demand letter are two separate letters.

 

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You shouldn't wait until that 41st day to contact your RAC and initiate a discussion period.  CMS has encouraged providers to contact their RAC as soon as possible early in the process immediately after the demand letter (for automated reviews) or the demand letter (for complex reviews) to start the discussion.  Getting a resolution with the RAC in the discussion period prior to the initiation of the recoupment process can save you recoupment dollars as well as costly appeals later that could be a very long process.

 

If the RAC agrees with your position, you stop the recoupment. If you are denied in the discussion period, you then still have the right to pursue the appeal process; the discussion period does not take away your right to appeal, nor does it affect your recoupment or appeal time frames.

 

Reasons to Initiate a Discussion

During the discussion period, the provider may provide additional information or documentation to the RAC for its consideration. For example, if the claim was denied due to missing documentation in the medical record that would have justified the services rendered, the provider may submit that information to the RAC. In addition, the discussion period maybe used by the provider to further discuss the finding with the RAC.  CMS suggests that providers consider both the discussion period as well as the appeal process when it comes to challenging claims. If you think you're going to launch an appeal, it is recommended that you file one immediately, because you possibly can risk having your funds recouped otherwise. But if you're sure that the RAC is wrong and you have documentation to support your case, CMS recommends you use the discussion period.



So what are some likely reasons for a discussion?

 

  • Trying to reverse the RAC's decision through this simpler process. Especially as you identify groups of similar denied claims, your goal is to convince the RAC that their decision was incorrect and to expedite the process of reversing the decision for multiple claims. Address these issues in groups of claims and provide support for your reasoning.

 

  • Providing additional information or provide additional support for missing or incomplete documentation. During the outreach sessions, CMS reinforced that providers shouldn't obviously create or alter documentation, but if a provider has documentation, but it is missing from the information received by the RAC, some RACs will accept the missing documentation after the fact. As an example, if a discharge summary had been dictated but never filed, the RAC would likely accept that during the discussion period. This is perhaps the most common reason to launch a discussion period.

 

  • Using it as a learning opportunity. Communication with the RAC may give you insight as to how they arrived at their decision. Providers should identify that information to identify patterns in other claims and to avoid making mistakes in the future.

 

  • Gathering information for the appeal process. Even if you don't prevail at the discussion level, every bit of information you collect in the process will help you as you embark on your appeal, should you choose to continue.


What does each of the RAC auditors say about the discussion period?


Like several other variances among the different RAC contractors, each RAC dispenses some slightly different information on the discussion period on their Web sites.  The following CMS and RAC websites have this information as of the publishing of this article:


CMS


Q: How long is the Recovery Audit Contractor (RAC) discussion period?


A: The discussion period begins with the time of notification (demand letter for automated reviews and the review results letter for complex reviews) through the time recoupment occurs. The discussion period normally requires written notification to the RAC. The discussion period does not extend the provider's appeal timeframes.


CGI


Q: If the hospital or provider disagrees with the CGI determination, what is the procedure to exercise the Discussion Period option?


A: Providers are encouraged to contact the CGI Medicare RAC B Call Center at 1-877-316-RACB (7222) or send an e-mail to racb@cgi.com.  (http://racb.cgi.com/Docs/CGI%20RACB%20FAQ.htm#_If_the_hospital)


Connolly


Nothing posted on the Web site at this time.


DCS


DCS (
http://www.dcsrac.com/faq.html):


Question:  During the "discussion period", if a record is discussed and agreement is reached that the provider is correct, will the provider receive a letter to that effect?


Answer:  If and when it is decided during the discussion period that the provider is correct, then DCS will notify the MAC of the decision. If the provider requests a letter stating the new results of the review, DCS will generate a letter stating the decision.


Question: Please clarify the procedure that a provider may follow if they disagree with the DCS determination and wish to discuss the account with DCS concerning the denial? (Discussion Period)


Answer:  The RAC discussion period begins with receipt of the review results letter for complex reviews or the demand letter for automated reviews. If a provider has any questions after receiving a letter they should contact DCS immediately to ask questions. The discussion period continues until the issue is resolved or recoupment is complete. This period is for the provider to contact DCS via telephone or written inquiry using the discussion form , and provide additional information they feel may support their original claim or request clarification from DCS as to why the denial was issued.


Question:  If a provider is in the discussion period with the RAC, is the appeal still due on day 31? What are the exact details and rules we must follow in regard to rebutting a decision during the "discussion period?"


Answer:  Yes the appeal is still due on day 31. Although the discussion period falls into the time frame when the provider can file an appeal, it is distinctly separate from the appeals process. We would encourage the providers to contact DCS shortly after receiving the Review Results Letter or Demand Letter and discuss the issue/issues they may have


Question:  Is there a process for sending a single piece of information during DCS' review/discussion period?


Answer:  Yes, you may use the discussion period form which may be faxed or mailed to DCS, or you may contact customer service via telephone.


Question:  Will DCS accept missing (additional) documents during the discussion period?


Answer:  Providers should provide all documentation to support a case when the medical record is originally sent. If a circumstance arises where all documentation is not sent with the original record, then the provider may submit this during the discussion period for review at the RACs discretion.


Question:  Due to confusion and continually changing policies, how will the RAC auditors be aware of the dates policies were amended, as well as implementation dates of interim policies, memos and related correspondence?


Answer:  The Recovery Audit Contractor (RAC) must abide by the Medicare legal and regulatory documents that were in effect at the time when the services were provided, to include the correct version of the Local Coverage Determination (LCD) by the Medicare contractor who had jurisdiction. The RAC must diligently research this regulatory backup and cite the correct authorities. If providers feel that a document was not considered or that an incorrect policy was invoked, they should bring this to the RAC's attention during the discussion period.


DCS has also posted a copy of a sample Discussion Period Request Letter as one of several samples of many of the documents that a provider might need or expect to receive from the RAC: http://www.dcsrac.com/faq_files/Discussion%20Period%20Request%20Form.doc


HDI

Nothing posted on the Web site at this time.


Every provider should consider including the discussion period as a part of its overall appeal strategy.  Initiating a discussion period is obviously a shorter and more efficient process than a long, drawn-out appeal process, but in some circumstances, especially in connection with denials based on medical necessity, an appeal may be more desirable. Discussions, however, would be called for in situations of medical necessity denials, for instance if new documentation is available to support the claim.  Ultimately, the discussion process may assist in your decision on whether to continue to appeal.


About the Author


Carla Engle, MBA, is a product manger for MediRegs, a Wolters Kluwer company. Her background includes more than 20 years in hospital and physician practice operations, particularly in reimbursement and billing functions. Prior to joining Wolters Kluwer recently, she was the vice president of compliance for a national revenue cycle solutions company and prior to that was in the Reimbursement Training Department with HCA.  For several years she headed up the Part A Fraud Investigation Unit for a CMS Program Safeguard Contractor (PSC) where she was successful in the prosecution of several national cases. In her revenue cycle compliance capacity, she worked with a number of clients in California and Florida with Recovery Audit Contractors (RACs) in setting up processes and appeals.


Contact the Author

carla.engle@wolterskluwer.com

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