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January 25, 2018

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Medical Coding News Archives

RAC Complex Review of Part B Claims Is Still on the Horizon

September 3, 2010:

Complex medical reviews of physician issues by recovery audit contractors had not begun as of September 2010 the Centers for Medicare and Medicaid Services had not yet authorized recovery audit contactors (RACs) to begin complex medical reviews of physician issues.

According to a CMS source, the agency is still discussing medical record limits with physician associations and so has not finalized the limits as of yet. The agency indicates that complex reviews will be able to begin, if a RAC chooses, sometime in the fall of 2010.

Recovery audit contractors review claims on a post-payment basis using Medicare policies, including national coverage determinations (NCDs), local coverage determinations (LCDs), and CMS manuals. RACS are permitted to conduct two types of reviews: complex (those that require medical records) and automated (no medical records are requested). Complex reviews are conducted for coding errors, DRG validation, and medical necessity.

When performing a complex medical review, the reviewer compares medical record documentation with claims to determine if the services were appropriately billed and if the medical necessity of the service is supported. When medical records are needed for reviews, the RAC may go onsite to the provider’s location to view and/or copy the records or request that the physician mail, fax, or securely transmit the records to the RAC. To reduce the burden on providers, CMS will place limits on the number of medical record requests.

In 2005, CMS announced the recovery audit contractor demonstration project in accordance with regulations contained in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The entire demonstration project recovered more than $900 million in overpayments between 2005 and 2008. The Tax Relief and Health Care Act of 2006 (TRHCA) made the RAC program permanent.


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