RAC UPDATE: 9-12-07 Dr. Jeffrey Kaufman

Dear Members:

I know quite a few of you are interested in the ongoing discussions we have had with CMS and the RAC contractor for California, PRG Schultz. I have been part of several phone conferences held with representatives of CMS and PRG Schultz that included Rick Rutherford and other administrative members of the AUA, attorneys for the AMA and representatives of CMA. No matter what your personal feelings are about this program, recognize that it is here to stay. In view of the ever increasing budget deficit facing Medicare, Congress has looked favorably at the fact that the RAC contractors are returning money to the system and has extended the program to all 50 states gradually enrolling them 2-3 at a time beginning in March 2008. It has now shifted from a pilot program to a permanent part of the Medicare audit system. In view of this, it is important that practicing physicians provide input into how the system can be made more workable. In our discussions, we have covered a wide range of administrative, logistical and other topics in an effort to refine the RAC system making it more user friendly and less onerous for practicing physicians.

Toward this end, we have secured a commitment from PRG Schultz to limit their look back interval to no more than 3 years (down from 4 years) beginning with the date the carrier processed the claim payment. That means that the multiple demands for repayment received by California urologists for LHRH agonist injections in the interval more than 4 years ago have all been rescinded. You should have all received letters to this effect by now. However, recognizing that those letters contained mistakes that indicated the original request for repayment was based on “duplicate payments” rather than on the least costly alternative policy, the RAC contractor is planning to call medical offices around the state to explain the situation more fully. We are hoping a new remark code will ultimately be available on future EOB statements that will explain that any repricing or demands for repayment are based on a RAC review rather than on some other carrier effort. Once the explanation codes are approved and in use, future efforts to recoup past payments should be much less confusing. In this same fashion, the contractor has been sympathetic to our request that letters requesting records or demanding repayment be made less threatening, more informative and easier to understand. We will be working with them on the wording of such letters.

Recognizing the enormous burden of responding to multiple requests for records or to demands for repayment, we have asked the contractor to consider making some reimbursement to doctor offices for their work much as they currently do to hospitals. While CMS doubts this will occur, we will maintain pressure for equity in the system recognizing the effort involved in responding to multiple records requests in a short time interval. Moreover, we are negotiating to have CMS and the RAC limit the number of records requests or repayment demands made in a given interval based on the size of the office involved and their ability to respond without disrupting the doctor’s ability to provide care to his patients. Details of these revisions to the system are still to be worked out but at least we have an ongoing dialogue with CMS and the RAC and they are now sensitive to our concerns in a way that was lacking previously.

Still to be considered are issues about the level of training of those who review records at the RAC. Currently, they are using nurses and pharmacists. We would like to see the final review performed by a physician with skill and knowledge about the area of medicine reviewed before a determination is made that repayment is indicated. We have also made our case regarding the interpretation of previous policies on which claims payments were made asking that the reviewers take into consideration understandings in place between the state carrier and practicing physicians at the time in question. Unfortunately, both the RAC and CMS are unwilling to consider anything other than a strict, literal interpretation of written policy. This only points out the importance of our own review of proposed drafts of new state carrier policies insisting that they be written correctly and reflect current practice standards. No longer can we rely on the understanding and good will of our state’s Medicare directors to interpret policy and pay claims appropriately since all payment practices will be subject to outside review by these third party RAC contractors. In the future, it will be ever more important to have CUA members comment on any new state Medicare policy that might impact their practice. I will do my best to alert members when those policies are published so that you may read and comment in a timely fashion.

Our discussions with CMS and the RAC agent are ongoing. Please notify me of your concerns and any untoward actions you feel the RAC has undertaken. I will continue to keep CUA members up to date in this area. Look forward to a written notice from Rick Rutherford from the AUA’s Practice Management group on this issue in the near future and my formal presentation and discussion at the Western Section meeting next month in Scottsdale.

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