Lessons learned from demonstration
The agency learned a number of lessons from the RAC Demonstration Project that were applied to the permanent program.
- The RACs are limited to reviewing claims paid up to three years earlier. They may not review claims paid before Oct. 1, 2007.
- The RACs may not conduct widespread reviews (automated or complex) without approval from CMS. Issues that have been approved for review must be made public and posted on the contractor’s website. If the RAC determines that there is a problem related to an issue not approved for review during the course of the review, it can request permission to conduct reviews on the new issue. If permission is granted, it must be added to the list. However, the RAC is not permitted to use a review to go on a fishing expedition for potential overpayments made on other issues.
- The RACs are not permitted to conduct claims reviews in a state undergoing a Medicare Administrative Contractor (MAC) transition, nor are they permitted to do so for three months before and three months after the transition. The only exception to this is if the new MAC was the carrier or fiscal intermediary in that state.
- Each RAC must hire a physician medical director and have certified coders available to assist with questions.
Record request limits
The RACs are limited in the number of records they can request in a 45-day period based on the number of enrolled providers, not just physicians, in the practice. The number of records a RAC is able to request is based on the group National Provider Identifier (NPI). Those limits for 2011 for providers are as follows:
- Offices with fewer than five providers: 10 medical records
- Offices with six to 24 providers: 25 medical records
- Offices with 25 to 49 providers: 40 medical records
- Offices with 50 or more providers: 50 medical records
- 1 percent of all billings from preceding calendar year per 45-day period
- 300 record cap per 45-day period