SCGhealth Blog


Provider relations coordinator intended to help with medical review process

Wednesday, September 24, 2014

If you feel like your Medicare Administrative Contractor (MAC) or your Recovery Audit Contractor (RAC) is breaking the rules of medical review, or you have process questions about how your medical review is being handled, you can now reach out directly to a CMS provider relations coordinator for assistance.

The agency announced the hiring of Latesha Walker for the newly created position only in early June, so it’s too early to tell whether the provider relations coordinator is impacting relationships between providers and medical reviewers. 

The fact that CMS saw the need to create the position, however, speaks to some of the larger frustrations providers have with the medical review process when it comes to being able to hold the MAC and the RAC accountable when needed. 

Even though providers have extensive rights during medical review, including the ability to appeal the findings of the reviewer to as many as seven different levels of review, it can feel particularly helpless to go through the medical review when questions arise about the process itself, rather than the findings being made about the claims.

CMS clarifies in its announcement that the purpose of the provider relations coordinator is to address those larger process issues. Questions about specific claims or review decisions should be directed to the MAC or RAC conducting the audit. 

However, in one example pointed out by CMS, if a provider feels that a RAC is failing to comply with the documentation request limitations in place for RAC audits, or failing to share results in a timely fashion, that’s a larger question to direct to the provider relations coordinator. 

You can also send suggestions for how to improve the MAC or RAC medical review processes, an open ended allowance that may result in numerous emails for Latesha Walker. 

For concerns related to medical review done by the MAC, direct your email to MedicareMedicalReview@cms.hhs.gov.  When it comes to the RAC, direct your email to RAC@cms.hhs.gov.

Hopefully, Walker can provide still more assistance to some of the traction providers have finally gained in what can be seen as a very stacked process. For example, one of the reasons RAC reviews are largely on hold while new contracts get awarded is because of provider complaints that RACs abused the limitations placed on the number of claims it could review. 

Among other approaches, one complaint was that a RAC would have a limit of claims to review for a relatively small facility, but direct 100 percent of its requests to a specific department, overwhelming it with the need to furnish documentation. In future RAC contracts, the RAC limits will be applied to specific departments, and the RACs will further be expected to request even fewer claims from entities with a high rate of overall billing compliance. 

When it comes to the MACs, there still remains confusion about how to apply extrapolation to the results of an audit, as well as extensive disagreements when it comes to code selections for E/M service levels. 

While recent changes have pushed back the time at which a MAC can begin to recover money as a result of medical review until the practice has had at least one appeal, the reality is that a large repayment demand, coupled with aggressive collection tactics, can devastate a small or even mid-sized practice. 

Even when the practice is exonerated at a higher level of appeal, by then these practices have been forced out of business or into a merger agreement. 

Time will tell how effective the provider relations coordinator will be – drop us an email if you’ve had any type of communication with Latesha Walker – we’d be very curious to know how it went. In the meantime, it presents at least the feeling that you have a specific point of contact at CMS when you believe that a provider needs to be held accountable. 


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