RAC Legitimate Advancements AND Methodologies FOR Effective Claims.

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RAC Lawful Improvements AND Techniques FOR Fruitful Requests Kathleen Houston Drummy, Esq. kathydrummy@dwt.com RACS MUST TARGET Asserts FOR Audit Utilizing Information Investigation Information mining procedures Office of Monitor General ("OIG") and GAO reports
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RAC LEGAL DEVELOPMENTS AND STRATEGIES FOR SUCCESSFUL APPEALS Kathleen Houston Drummy, Esq. kathydrummy@dwt.com LAX 12007883v1 0050033-000750

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RACS MUST TARGET CLAIMS FOR REVIEW USING DATA ANALYSIS Data mining methods Office of Inspector General (“OIG”) and GAO reports Comprehensive Error Rate Testing (“CERT”) Program reports Claims information outfitted by CMS (Demonstration Project)

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TYPES OF REVIEW Automated Review : If there is a reasonable inappropriate installment, the RAC has no compelling reason to assess the restorative record connected with the case and simply contacts the supplier to gather the excessive charge or pay the underpayment. Complex Review : If it seems likely that a case contains lapses, the RAC asks for medicinal records from the supplier and surveys the case.

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THE REVIEW PROCESS RACs must utilize the same Medicare approaches and rules and the same kind of audit staff utilized by Medicare cases preparing temporary workers. Suppliers may disprove an excessive charge determination in two ways: a casual rejoinder procedure or a formal request procedure.

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APPEALS CONCERNING THE RAC DEMONSTRATION An extensive number of the requests documented by suppliers in the three year RAC Demonstration tested therapeutic need or coding determinations made by the RAC. CMS underlined in the 2008 Status Report that just a little rate of RAC determinations were completely or incompletely toppled on bid. The CMS “success” figuring may be exaggerated.

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REBUTTAL Informal chance to work with RAC to question asserted excessive charge finding. Supplier must present a reply proclamation inside of 15 days of accepting notification of recoupment of an excessive charge. The RAC considers the counter explanation and other significant proof in figuring out if the choice is defended. This procedure is not an essential to the requests process and the Provider need not seek after counter. Supplier may in any case offer utilizing the formal advance procedure. Answer procedure may help with choice in respect to whether to keep on engaging.

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MEDICARE APPEALS PROCESS FOR RACS General : RAC determination may be advanced in basically the same way as any Medicare claim. Special case : The RAC beginning determination is spoke to the Medicare contractual worker that at first paid the case, not the RAC that made the starting determination.

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FIRST LEVEL OF APPEAL: REDETERMINATION Provider must demand redetermination in composing inside of 120 days of beginning determination. Special case : At minimum for Part B excessive charge determinations, if the Provider documents the notification of bid inside of 30 days of introductory determination, recoupment is conceded amid the initial two claim levels. MMA Section 935(a); CMS Transmittals 322 and 384.

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FIRST LEVEL OF APPEAL: REDETERMINATION (cont’d.) Overpayment withholding generally begins on day 41 Interest keeps on accrueing on excessive charge amid the deferral period AnMed Health v. Leavitt : Recoupment of Part An Overpayments There are no base prerequisites for the sum in debate.

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FIRST LEVEL OF APPEAL: REDETERMINATION (cont’d.) Medicare temporary worker has 60 days from receipt to choose whether to support RAC’s discoveries. The audit determination letter ought to express the basis for its choice. On the off chance that the case foreswearing is maintained, the Medicare contractual worker will give a clarification. The supplier can\'t assist the claim at this level.

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SECOND LEVEL OF APPEAL: RECONSIDERATION Provider must demand a reevaluation in composing for a survey by a Qualified Independent Contractor (“QIC”). Exemption : If Provider requests right on time to QIC, recoupment again is conceded, at any rate for Part B excessive charge determinations. There are no base prerequisites for the sum in debate.

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SECOND LEVEL OF APPEAL: RECONSIDERATION (cont’d.) The QIC must process the solicitation for reevaluation inside of 60 days. On the off chance that the QIC can\'t finish its choice in the relevant time span, it will educate the appealing party of its entitlement to move the case to a managerial law judge. Basic : All issues must be raised and all confirmation pertinent to the offer submitted to the QIC preceding the reevaluation\'s issuance choice. Truant an appearing of good aim for late entries, prove not submitted at the reevaluation level may be barred from thought at later levels.

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THIRD LEVEL OF APPEAL: ADMINISTRATIVE LAW JUDGE (“ALJ”) HEARING Provider may ask for a filing so as to hear before an ALJ the solicitation in composing with the substance determined in the notification inside of 60 days of receipt of the QIC’s reexamination notice. Appellants must send notification of the ALJ listening to demand to all gatherings to the QIC for reexamination. The base sum in contention for logbook year 2009 is $120 (balanced every year).

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THIRD LEVEL OF APPEAL: ADMINISTRATIVE LAW JUDGE (“ALJ”) HEARING (cont’d.) Written notification of the listening to date and area ought to be gotten no less than 20 days preceding the booked hearing. The listening to may be directed either in-individual, through feature video chat, or by phone. The ALJ might just survey prove already exhibited at the Second Level of Appeal, truant a finding of good purpose. Oral confirmation may be offered .

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THIRD LEVEL OF APPEAL: ADMINISTRATIVE LAW JUDGE (“ALJ”) HEARING (cont’d.) The ALJ may ask for that CMS or its temporary workers take an interest as a gathering. The ALJ must issue a composed choice inside of 90 days from the date that the Office of Medicare Hearings and Appeals gets the listening to ask. On the off chance that the ALJ can\'t issue a choice in the appropriate time allotment, the ALJ will tell the right\'s litigant to move the case to the Medicare Appeals Counsel (“MAC”). The ALJ choice is tying unless it is altered or turned around by the MAC or a government court.

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FOURTH LEVEL OF APPEAL: MAC REVIEW Provider may document a solicitation for survey with the MAC inside of 60 days of receipt of the ALJ’s choice. The solicitation must be in composing and must determine the issues and discoveries that are being challenged. The MAC may survey the ALJ’s choice all alone movement or at the solicitation of CMS. There are no base necessities for the sum in discussion .

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FOURTH LEVEL OF APPEAL: MAC REVIEW (cont’d.) No appearance is needed. The bid is constrained to the record made before the ALJ. The MAC must issue a determination inside of 90 days of the audit, either altering, switching, or remanding the ALJ choice. On the off chance that the MAC can\'t finish its choice in the relevant time allotment, it will advise the appealing party of the privilege to move the case to the government area for legal survey.

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FIFTH LEVEL OF APPEAL: FEDERAL DISTRICT COURT Provider has a last alternative to document suit in government region court inside of 60 days of receipt of the MAC choice. The base sum in discussion for 2008 is $1180 and for 2009 is $1220. The proof displayed at the government area court level is constrained to the authoritative record.

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APPEAL CONSIDERATIONS In choosing whether to advance, suppliers ought to consider: Is there clear Medicare direction or criteria to bolster or disprove the RAC’s determination? Is the clinical documentation sufficient? Is clinical backing accessible, specifically the treating doctor?

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APPEAL CONSIDERATIONS (cont’d.) Should outside specialists, including legitimate insight, be included and at what stage simultaneously? The expense versus the advantage of advance? Special, one time issue versus successive and progressing issue? Case must be completely grown ahead of schedule in the bid process so maintenance of any outside experts/lawyers comparably ought to happen before.

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RECENT DEVELOPMENTS The MAC has been exploring and remanding ALJ choices with respect to RAC determinations. For instance, suppliers have tested RAC determinations that there was “good cause” for reviving claims past one year.

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RECENT DEVELOPMENTS (cont’d.) The MAC, all alone movement, has been investigating ALJ choices holding that a Medicare contractual worker despicably revived claims past one year without making an evidentiary appearing of good purpose. See , e.g., In re Critical Care of North Jacksonville , Medicare Appeals Council, February 29, 2008; In re Memorial Hospital of Long Beach , Medicare Appeals Council, Julyâ 23, 2008; In re Providence St. Joseph Medical Center , Medicate Appeals Council, July 23, 2008.

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RECENT DEVELOPMENTS (cont’d.) The MAC’s remand depended on its determination that neither the ALJ nor the MAC have the ward to consider a Medicare contractor’s choice on whether to revive a case or whether the contractual worker met the “good cause” standard. The MAC inferred that CMS’s assessment and observing of temporary worker execution, not the advances procedure, offered the discussion for implementing the “good cause” standard.

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STAY OF RECOUPMENT AnMed Health v. Leavitt , Case No. 8:2008 CV02453 – HFF, U.S. Area Court, District of South Carolina: Pending case in which thirty-seven South Carolina doctor\'s facilities affirmed that CMS unlawfully recovered over $20 million in claime

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