Part B Insider (Multispecialty) Coding Alert

Published on Sun May 28, 2006 PDF

If the RACs recycle your appealed claims, contact CMS

The Recovery Audit Contractors, which have been looking strictly at hospital claims, are starting to look at physician claims now. If you're in New York, Florida or California, they could soon be on your doorstep.

Providers refer to RACs as "bounty hunters" because they only make money if they collect Medicare overpayments from you. They also will receive financial incentives if they find underpayments.

Problem: The RACs aren't supposed to look at claims that your carrier already denied and then paid on appeal. But several Florida providers have received requests from RAC Health Data Insight for claims that had already gone through the appeal process, consultant Chris Acevedo with Acevedo Consulting in Delray Beach, FL told the May 18 physician Open Door Forum.

In some cases, the RAC has sent an overpayment request for services that the carrier paid on appeal, Acevedo said. The RAC asked for charts on 11 previously-appealed claims from one provider in particular.

Pay attention: Most often, the RAC is asking for charts where the provider performed more than one procedure on the same day and used a modifier, Acevedo noted.

The RACs were "very, very responsive" when the Centers for Medicare & Medicaid Services brought this issue to their attention, says William Rogers, a physician who runs the Physician Regulatory Issues Team at CMS. "I was impressed with their responsiveness," he adds.

"They realized that there was a defect in their communication with the carriers," so they weren't aware that a set of claims had already been reviewed. Rogers says he wasn't aware that the RACs had asked for any repayments on previously appealed claims.

What to do: If the RAC asks for documentation on a claim which the carrier already reviewed, contact CMS, Rogers advises. "We would like to hear from any providers who are running into this problem."