Description:

This workshop is devoted to reviewing the current status of RAC activities along with due consideration to the new contracts, Scope or Works, and various RAC approved issues.  Included will be recent events surrounding the RACs and the backlog of appeals at the ALJ (Administrative Law Judge) and MAC (Medicare Appeals Council) level.  There are currently hundreds of thousands pf pending appeals.  OMHA (Office of Medicare Hearings an Appeals) has indicated that at least two years will be necessary to address current appeals.  OMHA has proposed several different ways to address the enormous backlog including statistical extrapolation, settlement conferences, and administrative agreements.  One of the main issues is that of medical necessity for inpatient admissions. The inpatient issues has sparked the development of the ‘Over 2-Midnights’ rule.  The QIOs (Quality Improvement Organizations) are also becoming involved with short-inpatient stays and the ‘Over 2-Midnights’ rule.  CMS has also proposed changes to the appeals process in order to expedite the resolution of the backlog of appeals.  The expansion of the RACs to the Medicare Advantage Programs is still in the works with the RADV (Risk Adjustment Data Validation) with a concentration on both comprehensive and condition-specific issues.

• What is the current status of the RAC program?
• Has there been a change in the Scope of Work for the new RAC contracts?
• Why are there so many appeals at the ALJ/MAC level?
• If there are delays in the appeals process, how will this affect our physicians and/or hospitals?
• How has OMHA (Office of Medicare Hearings and Appeals) reacted to the flood of appeals?
• Can the OMHA use statistical extrapolation to address the backlog?
• What are these ‘Settlement Conferences’?
• Who are the new RACs?
• Why have the number of issues for physicians been increasing.
• What are the key issues where the RACs are finding the greatest recoupments?
• How should physicians and hospital be working to have appropriate inpatient admissions?
• What is all the fuss about the ‘Over 2-Midnights; rule?
• Why did CMS decide to involve the QIOs in the ‘Over 2-Midnights’ rule?
• What happens when a hospital inpatient denial occurs?  Does this affect physician coding and billing?
• What do physicians need to document in order to justify hospital services?
• What is happening with the RACs and Part C or the Medicare Advantage program?

Teleconference/Webinar Objectives: 

• To Review Current RAC Activities
• To Review the Different SOWs for the Five Regions
• To Briefly Review the Overall RAC Appeals Process
• To Understand the Role of the Administrative Law Judges and the Medicare Appeals Council
• To Discuss the Enormous Backlog of Appeals at the ALJ/MAC level
• To Review CMS Proposed Changes in the Appeals Process
• To Assess The Impact of the Backlog Both Operationally and Financially
• To Review How OMHA (Office of Medicare Hearings and Appeals) Is Reacting to This Situation
• To Discuss One of the Main Issues Causing the Backlog – Hospital Inpatient Admissions vs. Observation Services
• To Review the Settlement Process and Administrative Agreements
• To Discuss the OMHA Proposal to Use Statistical Extrapolation
• To Briefly Review the ‘Over 2-Midnights’ Rule and the Subregulatory Guidance Being Issued Including QIO Involvement
• To Appreciate Common Physician Hospital Services and Associated Billing
• To Delineate Current and Anticipated Physician Issues
• To Review Current and Anticipated Hospital Issues
• To Review the Process of the RACs Auditing Medicare Advantage Programs Through the RADV audits.

Teleconference/Webinar Outline/Agenda: 

I.              Overview

a.    Objectives of the RAC Program

b.    Objectives of Other Federal Auditing Programs

c.    Emphasis on Hospital Recoupment

d.    Growing Number of Issues for Physicians/Clinics

e.    Common Issues for Physicians and Hospitals

II.            New RACs and Associated SOWs

a.    Five New RACs

b.    Guidance from the SOWs

c.    Possible Differences in Prioritization of Issues

III.           RAC Appeals Process

a.    ALJs – Administrative Law Judges

b.    MAC – Medicare Appeals Council

c.    Specific Timelines Within the Appeals Process

d.    How are Recoupments Handled?

IV.          Current Backlog of Appeals at the ALJ/MAC Level

a.    Number of Appeals

b.    Rate of Appeals Reaching the ALJ/MAC Level

c.    General Categories of Appeals

d.    OMHA’s Reactions and Operational Plans

V.           CMS Proposed Changes to the Appeals Process

a.    Increased Use of Attorneys

b.    Streamlining Processes

VI.          Major Concern for RAC Denials of Inpatient Admissions

a.    What Constitutes and Inpatient Admission?

b.    How Inpatient Is Different From Observation

c.    The ‘Over 2-Midnights’ Rule

                                        i.   Subregulatory Guidance

                                       ii.   Medical Staff Training and Guidance

                                      iii.   RAC Involvement

                                      iv.   QIO Involvement

VII.         OMHA Proposals to Resolve Backlog

a.    Statistical Extrapolation

b.    Administrative Agreements

c.    Settlement Conferences

VIII.       Trends in RAC Audit Issues

a.    Physicians

b.    Hospitals

c.    Crossover Issues for Hospitals and Physicians

IX.          RAC Audits of Medicare Advantage Programs

a.    Special Features of MA Programs

b.    Risk Adjusted Payment

c.    Auditing and Statistical Analysis Through RADV

X.           Additional Special Issues

a.    Pre-Payment Audits

b.    Issues Involving Statistical Extrapolation

c.    CMS Improvements in the RAC Process

XI.          Sources for Additional Information

Prerequisites for Participating:

A general understanding of health care compliance, the RACs, the OIG Work Plan and coding, billing and reimbursement compliance.

Suggested Attendees: 

Chief Compliance Officers, CBR Compliance Officers, Healthcare Auditors, Healthcare Compliance Personnel, Chargemaster Coordinators, Billing and Claims Generation Personnel, Patient Financial Management Personnel, Cost Accounting Personnel, Cost Report Personnel, Financial Analysts, Managed Care Contract Personnel, Revenue Enhancement Personnel, Chief Financial Officers, Chief Compliance Officers, Financial Planners, Clinic Managers/Administrators Utilization Review Personnel, Medical Staff Organization Personnel, Physicians, Non-Physician Practitioners, All Other Hospital Personnel Interested in Compliance and RAC Activities