The Recovery Audit Contractor (RAC) Performant Recovery, Inc. announced in January 2018 that they will be conducting a complex home health review for documentation and medical necessity. The review covers all states except: Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia. Claims having a “claim paid date” which is more than three years prior to the ADR date will be excluded.

There are select revenue codes that they will select from. They will do an annual additional development request (ADR) limit that will be one-half percent (0.5%) of the total Medicare paid claims from the previous year.

Providers have 30-calendar days from the RAC determination to submit a request for a discussion Period. The 30-day period begins from the date of the Review Results letter. The RAC has 30-days from receipt of the Discussion Period request to respond to the provider. Providers will be notified of the Discussion Period review outcome via a letter and the provider portal will be updated to reflect the date and outcome of the Discussion review decision. If the audit is overturned in the providers favor, the audit is closed and no further action will be required. If the audit decision is upheld, a demand letter will be mailed to the provider by the MAC.

Similar to the previous RAC contract, the recovery auditors will not make request more frequent than every 45 days.  The look back period for ADR requests remains at three years.

Tips to be prepared          

  • Conduct internal review of medical records for medical necessity
  • Incorporate a reminder or refresher educational session for all clinicians on documentation
  • Review all recertifications for medical necessity
  • Have the resources and knowledge in order to respond to the RAC timely
  • Have processes and resources in place to create appeals for any denial your agency receives

About The Contributor

Dawn Cheek, RN, Senior Clinical Consulting Manager

Dawn Cheek, RN, is a Senior Clinical Consulting Manager for post acute solutions at McBee. Dawn works with home health and hospice providers nationwide to perform Medicare compliance reviews and establish internal audit plans.