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Region 4 Recovery Audit Contractor (RAC) Review Results - Informational Letter11/22/2021JENNIFER SARTOR, COMPLIANCE OFFICERSUMMIT ASC25 CROSSROADS DRIVE SUITE 306OWINGS MILLS, MD 21117Dear Medicare Provider,The Centers for Medicare & Medicaid Services (CMS) has retained Cotiviti GOV Services (Cotiviti RAC 4),formerly HMS Federal (HMS) to carry out the Recovery Audit Contracting (RAC) program in Region 4. TheRAC program is mandated by Congress and supported by SSA §1893(f)(7) and SSA §1893(h)(1) and (3), has aprimary goal of identifying Medicare improper payments. Improper payments include overpayments andunderpayments. Improper payments may occur because of incorrect coding, lack of sufficientdocumentation or no documentation, use of an outdated fee schedule or billing for services that do notmeet Medicare’s coverage and/or medical necessity criteria etc
Your Right to DisagreeIf you disagree with our findings, you have the option to submit our Discussion Request Form, which mustinclude evidence to support why you believe the services you provided are covered by Medicare and wereproperly coded and correctly billed
• If the additional documentation you provide substantiates a change in our original finding, a review outcome letter will be sent providing the outcome of our review
• You have thirty (30) days from the date of this Review Results Letter, which is also the date of the Provider Portal notification, to submit the Discussion Period Request in writing. If you require an extension, for submission of the Discussion Period Request please contact us
• During this period, or during our review of your Discussion Period Request, Cotiviti RAC 4 will not submit the claim(s) for adjustments to your Medicare Administrative Contractor (MAC). After that period expires, the claim(s) identified as improper will be shared with your MAC and they will issue a Demand Letter outlining your appeal rights and repayment options
• You can find the updated Discussion Request Form including submission instructions at https://rac4info.cotiviti.com – including how a Physician or a Physician who is employed by your facility, not a consultant, may request to speak with Cotiviti RAC 4’s Medical Director. You may also track the status of your Discussion Period Request via the Provider Portal
This letter is to notify you that Cotiviti RAC 4 believes that Medicare has potentially made an improperpayment to you. A description of the claims associated with the improper payment can be found on theattached Audit Detail page. Data analysis shows that the claims paid by Medicare include a potentialaberrant billing pattern for the reasons listed on the attached Audit Detail
RAC 4 RAC 4 Address (877) 350-7993 Page 1 FRVW-LetterRef# 150395-2 The results of our data analysis justified reopening your claim under §1869(b) (1) (G) of the Social SecurityAct and 42 CFR 405.980(a) (1). These results also serve as good cause to reopen the claim, if required by42 CFR 405.980(b) (2), and 42 CFR 405.986,Based on the billing guidelines reviewed for the selected claim(s) Cotiviti RAC 4 found that some of theservices you submitted were not reasonable and necessary as required by §1861 of the Act, or did notmeet the Medicare coverage requirements as required in §1862 of the Act outlined in the attached AuditDetail page. Along with our claims payment determination, we have made limitations on liability decisionsfor denials of those services subject to provisions of SSA §1814, SSA 1833(e), and SSA §1835, SSA 1866 (a)(1)(A)(i)(42 USC 1395cc §1879 of the Act). Those claims for which we determined that you knew, or shouldhave known, that the services were noncovered have been included in the results of this review. Inaddition, we have made decisions as to whether or not you are without fault for the overpayment underthe provisions of §1870 of the Act. Those claims for which you are not without fault have been included inthe results of this review. Pursuant to 42 CFR 405.982 and 42 CFR 405.984 detailed information regardingeach claim and the findings identified during the review are attached to this letter
Discussion Period: If you believe that this improper payment determination was made in error, you maysubmit a request for a discussion period to support the billed services. The information must besubmitted to Cotiviti RAC 4 at the below referenced fax number or address within thirty (30) days of thedate of this letter. You may track the status of your Discussion Period Request athttps://rac4info.cotiviti.com
Cotiviti GOV Services (Cotiviti RAC 4) Attention: Discussion Period Review RAC 4 Address Fax: (702) 240-5510 Portal: https://rac4info.cotiviti.com Please submit a copy of the Audit Detail page along with your supporting documentation for each claim
The Discussion Period begins with the Review Results Letter for a complex medical record review or withthe Informational Letter date for an automated review. The discussion period is the opportunity to submita statement and accompanying evidence to the RAC indicating why the adjustment should not be initiated
A physician (or a physician employed by the provider) may also submit a request to discuss an improperpayment finding with RAC Contractor Medical Director within thirty (30) days from the date of this letter
The request may be submitted via fax at (702) 240-5510, via direct upload to the provider portal athttps://rac4info.cotiviti.com or by contacting a Provider Relations Representative at (877) 350-7993. Theoutcome of the discussion process could change how or if the claim will be submitted for adjustment. TheRAC will advise you of its decision in writing. Please include a copy of the discussion form for each claim,along with your supporting documentation. The Discussion Form is located at https://rac4info.cotiviti.com
To ensure that the request is received and processed timely we encourage you to submit the discussionperiod request immediately upon receipt of this letter. Do not bundle or submit comingled records formultiple claims/audits in one transmission
RAC 4 RAC 4 Address (877) 350-7993 Page 2 FRVW-LetterRef# 150395-2 If the discussion period request is not received within thirty (30) days from the date of this letter, or if theRAC determines that the submitted documentation does not support the billed service(s), the claim will besubmitted to your Medicare Administrative Contractor (MAC) for adjustment. Per CMS’ directive, the RAC isnot required to accept discussion period request received on or after the thirty-first (31st) day of this letterand cannot accept discussion period request after the claim has been submitted to the MAC for processing
A demand letter will follow which identifies the overpayment amount and outlines repayment options aswell as appeal rights. Do not submit refund checks to the RACs. Refund checks for RAC identified improperpayments should not be sent to the RAC or the MAC upon receipt of an Informational Letter for anautomated review, Review Results Letter for a complex review or the Discussion Period Review outcomeletter. Instead, Providers should wait to receive a demand letter, from the MAC, which identifies theimproper payment amount and outlines repayment options
Notice: "Good Cause” Language: Why Cotiviti RAC 4 Selected These ClaimsPursuant to applicable Medicare reopening regulations, including without limitation the Medicare ClaimsProcessing Manual, Ch.34, §10.6.1 and Ch. 3, §3.5.1, the claims noted on the attached Audit Detail wereselected for review for an underpayment or overpayment, as applicable, for the following reasons: 1. There is New and Material Evidence that was not available or known at the time of the determination or decision and may result in a different conclusion; and 2. The evidence that was considered in making the determination or decision clearly shows on its face that an Obvious Error was made at the time of the determination or decision
New and Material Evidence and Obvious Error made at the time of the initial determination include: a. Improper or incorrect application of Medicare billing or coding requirements; b. The medical or other necessary records associated with the claim were not reviewed prior to the initial determination, a coverage or coding determination based upon the information on the claim and its attachments could not be made and there is a high probability that the records do not support the services paid or the service is not covered, and copies of medical records are therefore needed to provide support for the claim; and c. At the time of the initial determination, data analysis techniques, editing and/or review processes were not applied to the claim
Cotiviti RAC 4 has reviewed the claims noted on the attached Audit Detail. In accordance with CMSregulations, Cotiviti RAC 4 data analysis techniques coupled with periodic OIG Reports(www.oig.hhs.gov/oei/reports/oei-03-01-00430.pdf; www.oig.hhs.gov/oei/reports/oei-07-06-00340.pdf,www.oig.hhs.gov/oei/reports), quarterly PEPPER Reports (The Program for Evaluating Payment PatternsElectronic Report, see http://www.PEPPERResources.org/), National and Local Coverage Determinations(NCD/LCD), Coding Clinic, CPT, CPT Assistant, DRG Expert, and National Correct Coding Initiatives Edits(NCCI) resources do not support the services paid, the services would therefore not be covered, and abilling or coding error therefore exists
RAC 4 RAC 4 Address (877) 350-7993 Page 3 FRVW-LetterRef# 150395-2 Thank you for your cooperation and prompt attention to this improper payment. If you have any questionsregarding this letter, would like to check the status of the discussion period review or discuss the improperpayment identification, please direct your inquiry to Provider Relations
Email: [email protected] (Do not include PHI) Phone: (877) 350-7993 Fax: (702) 240-5510 Mail: RAC 4 Address Portal: https://rac4info.cotiviti.comSincerely,Cotiviti GOV Services (Cotiviti RAC 4) RAC 4 RAC 4 Address (877) 350-7993 Page 4 FRVW-LetterRef# 150395-2
The Discussion Period begins with the Review Results Letter for a complex medical record review or with the Informational Letter date for an automated review. The discussion period is the …
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CMS has given approval for Cotiviti to begin audit activity for RAC Regions 2 and 3. Click here to be taken to the CMS Approved Issues list. Click here to see a description of prior Recovery Audit contract modifications, and their effective date (s). Submit a Discussion Request or Physician-to-Physician Review
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Review Outcome Letters have been enhanced to include the outcome of the Comprehensive Coding Review including all additional code changes, which may not impact the DRG assignment.