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Responding to RAC ADRs

In reviewing certain inpatient hospital claims, the RAC for Region B (covering the Midwestern states), CGI, and its subcontractor, PRG Schultz, are now requesting that nursing notes not be included in response to additional documentation requests (“ADRs”). Note that this directive is not consistent across all ADRs, as other ADRs specifically ask for nursing records.

All documents proving medical necessity (including nursing notes) should be submitted to the RAC by the health care provider, whether or not such documentation is requested. Nursing notes, in many cases, assist to establish the medical necessity for an inpatient hospital admission. Although the decision to admit a patient to the hospital as an inpatient can only be made by the physician, nursing notes, in many cases, detail relevant factors supporting a physician’s decision.

When RACs request medical documentation in support of a Medicare claim, PPS providers and Long Term Care providers are entitled to reimbursement for the production of the medical records. (The current reimbursement rate is 12 cents per page). CGI and PRG have indicated that reimbursement is available for all “requested” pages which are sent, whether or not these pages are used in the actual audit. Some providers are now experiencing difficulty in receiving reimbursement for costs related to producing nursing records, as such records are no longer “requested.”

The cost of not submitting all documentation proving medical necessity may prove greater than the cost of producing extra documents, even if the RAC ultimately does not reimburse the provider for this documentation. Concerns related to reimbursement for the production of medical records can be brought to the RAC or to CMS. State provider organizations also may be in a strong position to assist providers to receive appropriate reimbursement for records provided in response to ADRs.

For assistance in your audit defense or for more information on undertaking compliance, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510 or (212) 734-0128, or visit the HLP website.

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