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Home Health Not Subject to RAC Prepayment Demonstration Edits

By Home Care Unlimited of El Paso, Feb 24 2014 05:23PM

Home Health Not Subject to RAC Prepayment Demonstration Edits



February 21, 2014 03:18 PM


The Centers for Medicare and Medicaid Service (CMS) has confirmed that home health agencies will not be subject to the current Recovery Audit Contractor (RAC) prepayment demonstration project. CMS stated the reason there is no prepayment review for home health agencies is “because of our current procurement process for new Recovery Auditor contracts, we have decided to “pause” our Prepayment Review Demonstration. And, because of the timing of the pause, along with the fact that there will be a nationwide Recovery Auditor for home health claim reviews, we decided to remove the edits for home health claims at this time.”


CMS announced a RAC prepayment review demonstration project to begin in September 2012. The prepayment review demonstration was to include all provider types, but initially limited it to hospitals in seven states with high incidences of improper payments and fraud: Florida, California, Michigan, Texas, New York, Louisiana and Illinois and four with high claims volumes of short inpatient hospital stays: Pennsylvania, Ohio, North Carolina, and Missouri.


From what NAHC has gathered, there is no set planfor when other providers would be added.In January, however, CMS posted additional review topics and provider types that would be part of the prepayment review demonstration project in 2014.


Two home health issues were included:


Blepharoplasty - (Inpatient Hospitals, Professional Services & Outpatient Hospitals)

Skilled Nursing Facility and Coding Validation - (Skilled Nursing Facilities)

Trastuzumab (Herceptin), multi-dose vial waste – (Outpatient Hospitals, Professional Services)

Home Health – Medical Necessity & Conditions to Qualify for Services – (Home Health Agencies)

J9310 Rituximab Dose vs. Units Billed – (Outpatient Hospital)

Skilled Nurse Length of Stay – (Home Health Agencies)


National Government Services recently announced that home health would not be subject to the prepayment reviews under the demonstration. Since there had not been an announcement or information shared with the provide community, except a list of addition topics posted on the CMS web site, NAHC sought clarification regarding CMS’ plans to include home health in the RAC prepayment demonstration project.


In addition, the current post-payment RAC activity will soon slow down as CMS proceeds with its procurement process for the next round of Recovery Audit Program contracts.


The following is posted on the CMS RAC website:


“…. It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts. In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program. Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program. CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers. CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders. Providers should note the important dates below:


• February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)

• February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration

• June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment.”


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