The “Recovery Audit Contractor (RAC) Toolkit” includes background on the program and an overview of the process, including what entities are eligible to be audited, the basis for the audits, and the type of audits. It also includes appendixes providing:

• A preparation checklist
• The hierarchy of authority samples
• A sample of the RAC coordinator job description
• A sample of a RAC policy and procedure
• A RAC record extension request sample
• How to develop a RAC education program
• A presentation sample
• RAC acronyms
• A RAC determination response
• The appeal process workflow
• The Medicare appeals process
• Sample appeal letters
• An appeals submission checklist

The kit was developed by AHIMA’s Recovery Audit Contractors (RACs) Workgroup, a subgroup of the Clinical Terminology and Classification Practice Council. It is available free of charge.

AHIMA offers additional toolkits online, including “Copy Functionality Toolkit,” which can help HIM professionals and their organizations develop policies and procedures to allow for the review, audit, and testing surrounding this functionality. The “Health Information Exchange (HIE) Resource Toolkit” outlines the HIM issues in health information exchange, as well as useful Web sites that HIM professionals can reference in preparing for HIE.

Look for two more toolkits on amendments to transcribed reports and amendments for EHRs, which will be released in August.

“The automated reviews are less burdensome on the provider, because there’s no request for medical records,” said Marie Casey, deputy director of the Division of Recovery Audit Operations at CMS, in the news item. “They’re also easier for the RACs to manage.”

The delay for medical necessity auditing is due to the complexity of the reviews. “We’re delaying because it’s more difficult,” Casey said. “We are really trying to ensure that when there is a difference of opinion [on the medical necessity determination of the case], the RAC clearly documents their rationale.”

The delay will also help CMS roll out an issue review team, a group comprised of members from various agency divisions that will look at policy questions, such as whether the RACs have been correct in the interpretation of coding guidelines. These teams will look comprehensively at the questions before approving new issues for RAC review, according to Kathleen Wallace, a CMS representative who spoke at a May 28 Region D RAC training session held in Helena, MT.

When record requests do come, they will start sporadically but eventually fall into a pattern, at least in Region D, said HealthDataInsights president and CEO Andrea Denko, during the Helena training session.

PRG-Shultz will serve as a subcontractor to HealthDataInsights, Diversified Collection Services, and CGI Technologies and Solutions. Viant Payment Systems will serve as a subcontractor to Connolly Consulting. According to CMS, “the four RACs will contract with subcontractors to supplement their efforts.”

The program had been suspended last November when PRG-Shulz and Viant protested the contracts that had been awarded to four others. CMS plans to have four RACs in place by 2010. Each RAC will be responsible for identifying overpayment and underpayments in approximately a quarter of the country.

The Centers for Medicare and Medicaid (CMS) has reported on the status of the recovery audit contractor (RAC) program in Medicare for fiscal year 2007. In the report, CMS highlights improvements that will be made as it implements the permanent RAC program by 2010.

The improvements include a set limit on the number of medical records that contractors may request. The RACs will be required to have certified coders and a medical director on staff for document review and discussion if requested, and they will be required to have a Web-based application to provide status of cases in the permanent program by 2010.

CMS also has issued new guidance for hospitals that are appealing payment denials by the agency and its contractors. The improvement was mandated by Congress five years ago in the Medicare Prescription Drug Improvement and Modernizations Act.

The new guidance affects all Medicare appeals activity, including appeals of medical necessity review denials by fiscal intermediaries and Medicare administrative contractors,  as well as appeals of payment denials by recovery audit contractors.