By Cheryl E. Servais, MPH, RHIA
VP, Compliance and Privacy Officer
Despite all your preparations and internal processes intended to ensure accurate claims submission, there likely still will be instances in which your organization receives a demand letter from the RAC.
According to the RAC Statement of Work issued by CMS, demand letters, which must be sent via first-class mail, must include the following information:
- Identification of the provider(s) or supplier(s): name, address, and provider number
- The reason for conducting the review
- A narrative description of the overpayment situation: the specific issues involved that created the improper payment, any other pertinent issues and any recommended corrective actions
- The findings for each claim in the sample, including a specific explanation of why services were determined to be non-covered or incorrectly coded
- A list of all individual claims, including the actual amounts determined to be non-covered, the corresponding specific reasons for non-coverage, and the amounts denied
- For statistical sampling on overpayment estimation reviews, any information required by the Program Integrity Manual, chapter 3, section 22.214.171.124
- An explanation of the provider's or supplier's right to submit a rebuttal statement prior to recoupment of any overpayment (see PIM Chapter 3, Section 3.6.6)
- An explanation of the procedures for recovery of overpayments, including Medicare's right to recover overpayments and charge interest on debts not paid within 30 days, and the provider's right to request an extension for repayment
- Information on the provider's appeal rights
Where to Begin
As a provider, you should review the clinical and billing documentation for all claims listed in a letter to determine if the reason for the overpayment is supported by the circumstances recorded in the documentation. You also need to review the coding or billing standard, regulation, etc., that has been violated, according to the RAC.
Based on this initial review there may be grounds for rebuttal:
- If there is clinical documentation to support the original payment, then you can identify the documentation in the response.
- Whatever documentation that may have been overlooked by the RAC may be included in the rebuttal letter or as part of a Level 1 appeal. Some have suggested putting "sticky" arrow tabs by the specific phrase in the documentation that supports the rebuttal or appeal rationale.
An emergency room record shows a patient with lung cancer undergoing chemotherapy who reports to the ER with shortness of breath and collapses. The chest x-ray from the ER shows pleural effusion. Treatment in ER includes Albuterol, Atrovent, and Lovenox. Possible pulmonary embolus is noted by the ER physician.
The H&P lists the impression as chest pain to rule out pulmonary embolus.
A consultation with Dr. X states syncope, etiology undetermined.
A consultation with Dr. Y, held the same day, states syncope questionable orthostatic hypotension, possibly secondary to medication and chemotherapy. He recommends a CT of the head to rule out brain metastasis and orthostatic blood pressure testing, adding that he does not believe the patient has pulmonary embolus.
Progress notes recorded two days later, prior to discharge, by pulmonary documents the assessment as orthostatic hypotension, and an order to add Florincef and discharge the patient once all tests are completed is given.
Note that the discharge summary does not list a diagnosis reflecting the reason for admission determined after study. The physician ruled out pulmonary embolus, but did not state an underlying cause for the patient's symptoms. Pleural effusion was noted and could have caused the symptoms, as could have orthostatic hypotension. Orthostatic hypotension was worked up, confirmed, and treatment ordered, therefore, it can be supported as the principal diagnosis.
Appending Your Letter or Appeal
If the RAC applied an incorrect coding or billing standard or regulation to the claim, or if the standard or regulation was not interpreted correctly, you then can identify the correct standard or regulation or document the correct interpretation. In this case, material from "Coding Clinic," "CPT Assistant," Milliman and Roberts criteria, InterQual criteria, CMS Manuals, LCD documentation, medical journals and textbooks, or other official sources can be copied and appended to the letter or appeal.
You should state the date of the service and the date(s) of the appropriate citation(s) to show that the time periods are complementary.
If clinical documentation to support the codes assigned or the medical necessity of the service is not present in the medical record, other sources may be obtained to support the fact that services rendered were medically necessary. These sources may include query letter responses, notations from other providers or caregivers, utilization management or case management notes, patient schedules, sworn statements from those present while the service was rendered, etc.
In these instances, an explanation of any lack of original documentation should be combined with additional supporting documentation to substantiate the fact that the care was given and was medically necessary.
"The reason listed for the overpayment is that documentation does not support a postoperative complication of atrial fibrillation. Documentation reflects atrial fibrillation following surgery and the query letter submitted to the physician documents the physician's conclusion that the fibrillation was a complication of the surgery. A copy of the query letter and response is attached."
The time required to research, write, review and submit rebuttal and appeals documents can be extensive. You need to determine who will take on this responsibility if it is not outsourced to a consultant. Remember, too, that tight time frames for responding can complicate the process.
Rebuttal letters must be submitted within 15 days of the date of the demand letter from the RAC (in actuality, allowing for the mailing of letters, in about a week).
In order to stop recoupment, however, a Level 1 appeal must be filed within 30 days of the date of the demand letter. Although providers have a total of 120 days to file a Level 1 appeal, any appeal filed after 30 days probably will not stop the recoupment process.
It is a very sound suggestion to take time now to review your facility's staffing and workloads in order to assess if there is someone in your organization who can devote the time and effort necessary to write rebuttal letters or submit appeals. If not, you really need to look for help outside your organization.
Remember, time is not on your side.
About the Author
Cheryl E. Servais, MPH, RHIA, has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais's responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, plus 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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