We recently received our first Post-Payment RAC (Recovery Audit Contractor) Complex Review Audit for Continuous Glucose Monitoring (CGM). Now that the PHE waivers have expired, the RAC has updated the date of service (DOS) exception, excluding services provided prior to November 12, 2023, consistent with CMS post-PHE guidelines.

Since many CGM-only providers may be unfamiliar with the RAC audit process, here’s a simplified breakdown to help set clear expectations:

What to Expect from a RAC Audit:

1. Receiving the Audit Request: Once your company is selected for a RAC audit, you will receive a request letter (similar to the example in “Figure 2”). This letter could involve one or multiple claims, depending on your company’s billing activity.
2. Response Deadline: Suppliers will have 45 days from the date of the letter to respond. Responses can be submitted via fax, mail, or electronically through the Electronic Submission of Medical Documentation (ESMD) system, similar to other Medicare audit processes.
3. Audit Outcomes:
   • If your submitted documentation is sufficient, you will receive a “No Finding” result letter, meaning no further action is required and you can stop tracking the audit.
   • If the documentation is insufficient, you will receive a findings letter outlining the reasons for claim denial.
4. Challenging a Denial: After receiving a denial, suppliers have a small window of time to challenge the decision during the open discussion period. If your challenge is successful, the denial will be overturned and no further action will be required. However, if your challenge is unsuccessful or you decide not to pursue the open discussion request, the claim will be referred to the Medicare Administrative Contractor (MAC) for overpayment recovery. At this point, you will still have the option to appeal.

Key Considerations for Suppliers:

• Update Your Mailing Information: Ensure that your mailing address and contact information are current with the RAC. You can update this information on Performant Financial’ s website under the CMS RAC section: Performant Financial – CMS RAC – Update Provider Contact Information. Performant also offers a portal where you can check the status of your claims and any selected for audit: Performant Recovery Website Login Page.
• Understanding Your Claim Volume: The number of claims you have billed will determine your audit volume. The formula used to calculate Additional Documentation Request (ADR) limits is published by CMS and will be summarized in your request letter (an example of which is provided in “Figure 1”). These limits are clearly outlined, giving suppliers a clear understanding of the scope of the audit.

Final Thoughts

It will be interesting to observe whether RAC audits for CGM follow the more simplified trends often seen with MACs or if they align more with the rigorous reviews typically associated with UPIC (Unified Program Integrity Contractors).

Providers should be prepared for either scenario and ensure all documentation is accurate and timely to avoid unnecessary challenges.

For further information on the RAC process, visit Performant Financial – CMS RAC – CMS RAC Resources – Region 5.

FIGURE 1:

FIGURE 2: