The A/B MAC, Durable Medicare Equipment MAC and Home Health/Hospice MACs, as well as the current FIs and Carriers are outlined below. Please note that contractual protests may delay the implementation of a MAC for a specific jurisdiction.

Jurisdiction 6:

Jurisdiction 8:

Jurisdiction 15:

J15

Durable Medical Equipment MAC, Jurisdiction B: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin

JB-DME

Home Health/Hospice MAC: Illinois, Indiana, Kentucky and Ohio

HH1

Home Health/Hospice MAC: Michigan, Minnesota and Wisconsin

HH2

Provider Outreach

How often will CGI provide onsite provider outreach?

CGI will conduct outreach whenever feasible and practical. Initial outreach events must be completed in all Region B states before CGI may begin review.

Will the outreach be done in person or via conferencing?

Outreach efforts will be done both in townhall meeting settings as well as web and audio conferences.

Provider Information

How will CGI obtain RAC contact information for providers?

CGI will receive a data file over a secured data line from each MAC/FI/Carrier containing facility/provider information. CGI will use this contact information, unless the provider supplies an update via electronic mail or by contacting the CGI Call Center. Providers are encouraged to keep all contact information current.

CGI Website

What is the website address for RAC Region B?

The CGI RAC Region website is located at http://racb.cgi.com.

When will CGI have their web-based claim status system operational for providers?

This portion of the website is required to be implemented by January 2010 and CGI will comply with that requirement.

New Issues, Areas for Review

What areas does CGI intend to request CMS approval for audit?

CGI is required to obtain CMS approval for all areas of review that we have identified. Any potential new issue must be reviewed and approved by CMS and then posted to the CGI website before we can perform a review. CMS approved areas of review will be posted on our RAC B website.

How will CGI communicate new issues for review to state hospital associations?

CGI encourages state hospital associations to view all CMS approved new issues on our website,http://racb.cgi.com. Additionally, the provider outreach team will work with state associations and other identified parties to share RAC information.

Auditing

How are claims selected for audit?

CGI will use proprietary software and systems as well as our knowledge of Medicare rules and regulations to determine what areas to review.

Who will be auditing my claim?

Physicians, registered nurses, therapists and certified coders will be utilized to perform complex medical reviews.

Will all audits be conducted at the facility or provider location?

No they will not. However, a determination of whether to conduct an onsite audit will be made based on the scope as well as the volume of medical records to be reviewed.

If an onsite audit is scheduled, how many CGI staff will be assigned to review at the provider site?

Assignment will depend on the scope of the audit as well as the volume of medical records to be reviewed.

Where are CGI auditors located?

CGI has a staff of excellent, experienced medical auditors located in many states across the country.

What is done to protect confidential data during an audit?

All provider data is maintained according to HIPPA guidelines.

What is the maximum number of CGI staff that could be physically present at the provider site?

CMS has indicated that no more than two auditors will be part of an onsite audit team, provided an onsite review is scheduled.

How often will CGI conduct onsite provider reviews?

CGI will make those decisions on a case-by-case basis.

If CGI denies a hospital claim for services, will they also deny the physician claim for services?

No, Part A and Part B claims will be reviewed independently according to CMS guidelines.

What utilization criteria will CGI be using to review for medical necessity?

CGI will utilize the rules for National Coverage Determinations (NCD), Local Coverage Determinations (LCD), HCPCS, ICD-9 (ICD-10 when implemented and appropriate) and CCI that were in effect on the date of service.

Will the RAC review any other Medicare plans, such as Medicare Advantage?

The RAC will review Non-MSP Medicare Fee-for-Service claims only. Medicare Advantage claims are not in scope for the RAC project.

Will CGI accept physicians’ notes from their offices to support the request for services?

Yes. Providers are encouraged to submit all supporting documentation with the initial medical record request. During the initial discussion period, supporting evidence for a request for services will be accepted.

Underpayments

What is an underpayment?

A Medicare underpayment is defined as those lines or payment group (e.g., APC, RUG) on a claim that was billed at a low level of payment. The services should actually have been billed at a higher rate; thus, resulting in a refund to the provider.

How is it determined that an underpayment was identified?

CGI will use proprietary algorithms to determine underpayments as well as overpayments. CGI reviews each claim line or payment group and considers all possible occurrences of an underpayment that are in that one line or payment group.

What is the process when CGI identifies an underpayment?

CGI reviews claims using automated or complex reviews, to identify potential Medicare underpayments. Upon identification, CGI communicates the underpayment finding to the appropriate MAC/FI/Carrier. Once the appropriate MAC/FI/Carrier has validated the Medicare underpayment, CGI issues a written notice to the provider. The Underpayment Notification Letter includes the claim(s) and beneficiary detail.

Why are medical records being requested for an underpayment?

CGI will request the medical record, if necessary, to substantiate the validity of the underpayment.

When will CGI reimburse providers for the payment of requested medical records sent for an underpayment?

CGI is required to pay for medical records within 45 days of receiving the medical record.

When will I get my underpayment money returned from the MAC/FI/Carrier?

Once the MAC/FI/Carrier adjusts the underpayment and the underpayment processes through the system, the adjustment will be included on the provider’s next available remittance advice.

Can I appeal an underpayment?

No. The provider does not have official appeal rights in relation to an underpayment determination. However, the provider may utilize an initial discussion period to present any concerns to the RAC.

Can CGI provide a draft timeline for underpayments so the providers can better understand the framework that CGI is utilizing?

Overpayments

What is an Overpayment?

A Medicare overpayment is defined as those claim lines or payment groups (e.g., units, APCs, RUGs, etc.) on a claim that were billed incorrectly. The documentation does not support services billed, the payment exceeds the Medicare allowed amount or Medicare made a payment for non-covered services or items.

I received notice of an identified overpayment. What does it mean?

The notice of an identified overpayment indicates that CGI will pursue the recoupment of Medicare overpayments in accordance to the guidelines set by CMS.

How is it determined that an overpayment was identified?

CGI will identify a claims overpayment where there is supportable evidence of the overpayment. There are two primary ways of identification:

1. Through “automated review” of claims data without human review of medical or other records

2. Through “complex review” which entails human review of a medical record or other documentation

The determination process for identifying overpayments is summarized in four steps:

CGI documents the rationale for the determination listing the review findings with a detailed description of the Medicare policy that was violated.
The review goes through the validation process which may require further review from the MAC/FI/Carrier but essentially routes to CMS for final validation.
CGI communicates with the provider about improper payment (Review Results Letter).
Depending on whether the determination is either a full or partial denial, the overpayment amount is determined.

What is the dollar limit for a denial determination on an overpayment?

CGI does not recoup or forward any claim to the MAC/FI/Carrier for adjustment if the amount of the overpayment is less than $10. Claims less than $10.00 cannot be aggregated and recouped.

What if I do not agree with the Review Results Letter?

A provider has an initial discussion period to present additional information to support the services billed. If the provider does not agree with the decision, then the provider has 120 days from date of the First Demand Letter to file an appeal of the determination.

Automated Review

What is an automated review?

An automated review is a review that occurs when CGI makes a claim determination at the system level without a human review of the medical record.

Can I appeal on an automated review?

Yes. The first level of an appeal is called a redetermination and is handled through the provider’s MAC/FI/Carrier. A provider will have 120 days from the date of the Demand Letter to file an appeal timely. The provider may forward their appeal request and all supporting documentation to the provider’s MAC/FI/Carrier.

What procedure does CGI plan to utilize to coordinate recoupments with the MAC/FI/Carriers?

CGI forwards all identified improper payments to the MAC/FI/Carriers. The recovery techniques shall follow the recovery guidelines of all applicable CMS regulations and manuals, as well as all federal debt collection standards.

Will these recoupments appear on a separate Remittance Advice that clearly identifies they are the result of a RAC audit?

The provider will receive a Demand Letter from the RAC, in addition to, a Remittance Advice notice from the MAC/FI/Carrier, containing details of the automated findings. Reason code N432 is used on the Remittance Advice to identify adjustments based on a RAC review.

Complex Review

What is a complex review?

Complex medical review involves the application of clinical judgment by a licensed medical professional or certified coding specialist in order to evaluate medical records. Medical records include any medical documentation, other than what is included on the face of the claim that supports the services that are billed. CGI will use complex medical review in situations where there is a high probability (but not certainty) that the service is not covered or where no Medicare policy, Medicare article or Medicare sanctioned coding guideline exists. During a complex review, CGI will request medical records to substantiate services billed.

Can I appeal a complex review?

Yes, a provider has 120 days from the date of the Demand Letter to file an appeal of the determination to the MAC/FI/Carrier.

Medical Records Request

How can a provider send requested medical records to CGI?

CGI will accept medical records from the provider through the US Postal Service mail, any express delivery service, by CD via any of the previously described mail services or by faxing the record to CGI.

What are the medical record request limits for my facility?

Medical records request limits vary by both the size of medical practice or facility and also by the percentage of average monthly Medicare claims for the practice or facility.

For individual practitioners, the limit is set at 10 medical records per 45 day period.

For a partnership of two to five individuals, the limit is 20 medical records per 45 day period.

For groups of six to 15 individuals, the limit is set at 30 medical records per 45 day period.

Large groups consisting of 16+ individuals the limit will be 50 medical records per 45 day period.

For Inpatient Hospital, IRF, SNF, Hospice by NPI, the percentage of monthly Medicare claims are factored in.

10% of average monthly Medicare paid claims per 45 days

Maximum of 200 medical records per 45 days

Example 1: Local Community Hospital

1,200 Medicare paid claims in 2008

Divided by 12 = average 100 Medicare paid claims per month

x 10% = 10

Limit = 10 medical records per 45 days

Example 2: Major Medical Center

12,000 Medicare paid claims in 2008

Divided by 12 = avg 1,000 Medicare paid claims per month

x 10% = 100

Limit = 100 medical records per 45 days

Other Part A Billers (Outpatient Hospital, Home Health, etc) by NPI

1% of average monthly Medicare paid services per 45 days

Maximum of 200 medical records per 45 days

Example 1:

1,500 Medicare paid services in 2008

Divided by 12 = avg 125 Medicare paid services per month x 1% = 1.25

Limit = 2 records/45 days

Example 2:

360,000 Medicare paid services in 2008

Divided by 12 = avg 30,000 Medicare paid services per month x 1% = 300

Limit = 200 records/45 days (capped at the maximum)

How does the provider update the address of the individual that will receive the medical records request?

Providers can e-mail their contact information to racb@cgi.com. The CGI Medicare RAC B Call Center should be contacted at 1-877-316-RACB (7222), or via e-mail, should any information require an update.

How long does the provider have to send in the medical records?

CGI must receive the medical record within 45 days of the request.

What happens if the provider misses the deadline?

Providers will receive a reminder notice from CGI prior to the deadline. If the medical record is not received within 45 days, the claim may be denied. However, CGI will work with providers who may be concerned about meeting the deadline.

Will CGI pay for all requested medical records or just certain types?

CGI will pay for copies of medical records associated with review of acute care inpatient prospective payment system (PPS) hospital (DRG) claims and long-term care hospital claims.

What is the amount that CGI will pay for medical records?

RACs, including CGI RAC B, shall comply with the formula calculation found at 42 CFR §476.78(c) of the Code of Federal Regulations, Title 42 – Public Health.

If a hospital or provider utilizes an electronic medical record system, what documentation will they be required to provide to CGI?

The provider must submit all documentation that support the services rendered. The Medical Record Request Letter will contain a detail listing of all documentation being requested.

I never received a Medical Record Request List and now I have a Demand Letter. What do I do?

Contact CGI immediately to ensure that CGI has the correct provider contact information. Note that a determination may be appealed up to 120 days from the date of the Demand Letter.

I never received a Medical Record Request List and now I have a Demand Letter. How can I appeal this?

Contact CGI immediately to ensure that CGI has the correct provider contact information. The first level of appeal is initiated by the provider through their respective MAC/FI/Carrier.

Review Results Letter

How will CGI send the Review Results Letter?

Review Results Letters will be sent via US Postal Service Regular First Class mail.

Will a Review Results Letter be sent for an automated review?

No. The provider will receive only the Demand Letter for an automated review. This letter will contain the rationale for denial and regulation that was violated, in addition to, appeal rights information.

What is the Review Results Letter process and what do I have to do?

Once CGI has received the requested medical records from a provider, the audit team has 60 calendar days from receipt of medical records to review all supporting documents in the record, make a claim determination and send the Review Results Letter to the provider. Providers are afforded an initial discussion period for questions about the review process.

I have more information to provide after reviewing my Review Results Letter. How can I provide that information?

Providers have an initial discussion period to provide supporting documentation. Every effort should be made to send all requested information in response to the Medical Record Request Letter. Instructions for providing further evidence or information are included in the Review Results Letter. In addition, providers can contact the CGI Medicare RAC B Call Center at 1-877-316-RACB (7222) or via e-mail at racb@cgi.com.

What justification will be included on the Review Results Letters?

The Review Results Letter will document all rationale for the claim determination. These rationales will include a detailed description of the Medicare policy or rule that was violated and a statement as to whether the violation resulted in an improper payment.

Discussion Period

If the hospital or provider disagrees with the CGI determination, what is the procedure to exercise the Discussion Period option?

Providers are encouraged to contact the CGI Medicare RAC B Call Center at 1-877-316-RACB (7222) or send an e-mail to racb@cgi.com.

First Demand Letter

I received a Demand Letter. What does it mean?

Once an overpayment is discovered and a final determination is made, a First Demand Letter is sent. The RAC is required to follow the same practices for sending a Demand Letter as those applicable to MACs. Demand Letters instruct providers to send payment to the MAC. Payments received by the MAC are deposited and the MAC is required to update the RAC within seven calendar days of applying the payment.

When is the First Demand Letter sent?

During either an automated or complex review, the First Demand Letter is sent in conjunction with the issuance of the Remittance Advice from the MAC/FI/Carrier.

What is included in the content of the Demand Letter?

A sample of the RAC B Demand Letters will be posted on our website for providers’ convenience.

How long from the First Demand Letter do I have to pay before interest starts accruing?

If an overpayment is not paid in full or a valid appeal is not filed within 30 days of the date of the Demand Letter, interest will start accruing on day 31..

Recoupment

What is recoupment?

Recoupment is defined as the recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare provider payments and applying the amount withheld to reduce the debt. The MAC/FI/Carrier handles the recoupment of payments.

When does recoupment start?

If a full payment is not received 40 days after the date of the First Demand Letter and the provider does not file an appeal in the first 40 days of receipt of the Demand Letter, the MAC/FI/Carrier will begin the recoupment process on day 41.

When/how will I be notified when recoupment starts?

The provider will be notified of the date in the First Demand Letter.

Can I make payment arrangements instead of auto recoupment?

Yes, a provider can repay the MAC/FI/Carrier within 30 days, interest free or make arrangements for an extended payment plan. Interest accrual will begin on day 31.

Second Demand Letter

When is the Second Demand Letter issued?

If no response to the First Demand Letter is received from the provider, a Second Demand Letter shall be sent 30 days after the First Demand Letter. Note that recoupment starts 41 days after the issuance of the First Demand Letter and would have started by the time the Second Demand Letter is issued, provided appeal rights were not exercised by the provider.

Can I still appeal?

Yes, providers can appeal up to 120 days after the date of the First Demand Letter.

Third Demand Letter

When is the Third Demand Letter issued?

If the overpayment has not been recouped and the debt is eligible for referral to the Department of Treasury, an intent to refer to the Treasury or Third Demand Letter, shall be sent to the provider 30 days after the Second Demand Letter.

Can I still appeal?

Yes, if it is up to 120 days after the date of the First Demand Letter.

Appeals

Do I have appeal rights?

Yes. The first level of an appeal is called a redetermination and is handled through the MAC/FI/Carrier. Providers will forward appeal requests and all supporting documentation to the MAC/FI/Carrier. More information on appeals can be found at the CMS RAC website, http://www.cms.hhs.gov/RAC/, under Related Links Inside CMS.

What is the timeframe to appeal?

The timeframes to appeal are outlined in the diagram below.

What are the levels of the appeal process?

The levels of appeal are outlined in the diagram below.

DME

Who is the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction B (associated with RAC Region B)?

National Government Services, Inc. was awarded the Jurisdiction B DME MAC for the RAC Region B states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.

When does CGI anticipate conducting recovery auditing functions for DME claims in Jurisdiction B DME MAC?

In accordance with the RAC expansion schedule, CGI must perform all initial RAC outreach activities, submit and gain CMS approval for new issues for review and post approved new issues to our website before implementing DME auditing functions.

What areas does CGI intend to request CMS approval for DME audits?

Through data analysis, providers are identified for targeted review. Claims are selected as those claims that are most likely to contain an improper payment (coding error, coverage issue or medical necessity).