RAC Audits, also known as Medicaid
Medicaid
Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services. The Health Insurance As…
What are RAC audits?
Nov 16, 2021 · Medicare Recovery Audit Contractor Audits (RACs, or RAs) were introduced beginning in 2005 to identify and recover improper payments made in Medicare and Medicaid transactions between providers and payors. They were (and are) conducted by Recovery Audit Contractors (also known as RACs).
What Medicare claims do RACS review?
RAC Audits, also known as Medicaid Audits, Medicare Audits, MAC Audits, or MIC Audits are ongoing, aggressive, intrusive programs with the sole purpose of recovering reimbursement from health care providers. These audits are expected to become more frequent for the foreseeable future.
What is a Medicare Mac audit?
Apr 13, 2021 · RAC audits are run by the Centers for Medicare and Medicaid Services (CMS). Their goal is to uncover improper Medicaid and Medicare claim payments and get the money back. RAC auditors have collected back over $2 billion for CMS.
What is the Medicare Recovery Audit Contractor program?
The Recovery Audit Review Process: Recovery Auditors review claims on a post-payment basis Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals Three types of review: o Automated (no medical record needed) o Semi-Automated (claims review using data and potential human
What are RAC audits looking for?
They look for improper payments RAC looks for both overpayments made to patients and underpayments made to providers. While many RAC audits do uncover fraud, it is important to note that innocent mistakes or errors in documentation can also trigger an audit.Nov 29, 2016
What triggers RAC audits?
RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare's clinical payment criteria, documentation and billing requirements.
What triggers a Medicare audit?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What are the two types of Medicare audits?
Types of Medicare AuditsRecovery Audit Contractor (RAC) Audits.The Certified Error Rate Testing (CERT) Audits.Probe Audits.Check the address on the letter and ensure that it is the address of your practice.Make contact with the auditors.Keep copies of all transmitted documents to the auditors.More items...
How many years back can Medicare audit?
three yearsMedicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.Nov 1, 2015
How do I prepare for a RAC audit?
Here are five ways you can prepare.Perform an Internal Audit. This action will help you to determine the likelihood of coding and billing mistakes within your company.Identify and Correct Coding/Billing Issues. ... Review Problem Areas. ... Check Documentation. ... Find Assistance.Mar 31, 2021
What happens if you fail a Medicare audit?
If you fail to comply with the request, you will not receive reimbursement for the submitted claims. Even if you comply but the documentation doesn't support what you billed for, you won't get reimbursement.Jan 6, 2015
Are Medicare audits random?
For example, the Medicare program is required to make random audits of 10% of all Medicare providers on an ongoing basis. An audit or investigation can result from complaints by patients about the quality or appropriateness of the care they received, or how they were billed for their care.May 18, 2021
What are the 3 types of audits?
There are three main types of audits: external audits, internal audits, and Internal Revenue Service (IRS) audits. External audits are commonly performed by Certified Public Accounting (CPA) firms and result in an auditor's opinion which is included in the audit report.
Why do CMS and RAC auditors have the right to access your medical records?
RAC auditors will usually request medical records to complete the audit. For example, they may request medical records that detail a more complex procedure to ensure you were paid correctly for the services you provided.Apr 13, 2021
How many years back can Medicare recoup payments?
3 calendar yearsFor Medicare overpayments, the federal government and its carriers and intermediaries have 3 calendar years from the date of issuance of payment to recoup overpayment. This statute of limitations begins to run from the date the reimbursement payment was made, not the date the service was actually performed.Jan 4, 2017
Compliance
The burden of compliance is the responsibility of healthcare providers. Outside of basic written guidelines, Medicare will not provide any specific guidance to the physician or provider.
RAC Fees
RAC contracts fees are contingency-based, so auditors have every incentive to discover errors. RAC contingency fees vary and are established during contract negotiations with CMS.
How to appeal overpayment?
If the audit of your records determines you received an overpayment, you will receive an overpayment demand letter from the RAC. After receiving a demand letter, you are required to call the RAC within 15 days to discuss how you plan to proceed. In response to an overpayment demand letter, you essentially have three options: 1 Pay it in full 2 Request an extended repayment schedule 3 File an appeal
What is RAC audit letter?
If your practice receives a RAC audit notification letter, it’s generally to investigate suspicion of an improper payment on a claim (either an overpayment or an underpayment). RAC auditors will usually request medical records to complete the audit. For example, they may request medical records that detail a more complex procedure to ensure you were paid correctly for the services you provided. Medical records that don’t meet the criteria for medical necessity or claims that contain CMS coding violations could uncover an overpayment. In these cases, you could be required to send the money you previously received back to CMS.
How long does it take to get an overpayment letter from the RAC?
After receiving a demand letter, you are required to call the RAC within 15 days to discuss how you plan to proceed. In response to an overpayment demand letter, you essentially have three options:
Who is Jody Erdfarb?
Just make sure to stay on top of the deadlines because if you miss one, you’re out of luck. Healthcare attorney, Jody Erdfarb, JD, can help you prepare for a RAC audit and appeal during her online training. Jody will help you be better prepared should you be targeted for a RAC audit.
What to do if you disagree with a demand letter?
If you disagree with the overpayment demand letter you received, you have the option to appeal the findings. There are five different levels of appeals, and each one has its own set of deadlines that you must adhere to.
What is RAC audit?
What Are Recovery Audit Contractor (RAC) Audits? Also known as a Medicare audit or a MAC audit, the Recovery Audits Contract (RAC) program is an aggressive campaign seeking reimbursement from healthcare service providers. These audits have become increasingly frequent over the past few years, and they will continue to for the foreseeable future.
What is Medicare Recovery Audit Contractor?
These include services that are deemed “not reasonably necessary.”
What is automated review?
These audits, also known as automated reviews, aim to search for and identify any suspicious claims from healthcare providers. They use proprietary algorithms to ensure compliance and that healthcare providers aren’t charging or claiming funds incorrectly.
What to do if you are subject to a RAC audit?
If you are subject to a RAC audit, make sure to make an informed decision selecting an attorney. You’ll need an experienced team well versed in this subject to effectively refute fraud claims, especially in complex RAC audits.
What is RAC audit?
The RAC audits were developed in accordance with the Medicare Modernization Act of 2003. The program reclaims money by reviewing fee-for-service (FFA) claims – a process that has come to be known as a “clawback.”. The RAC audits essentially divide the country into four regions.
Who should be the liaison for an audit?
Ideally, the liaison should be you or your office manager . This liaison will need to know where to find the information that the auditors request. They should be there with the auditors when they inspect the office.
Do auditors want a private room?
The auditors will most likely want a private, separate room that they can use and have their meetings in. Ensure that the room is clean and that fixtures are in top shape. Remember that the auditors might want to conduct interviews with all employees.
What to do if you are subject to Medicare audit?
If you are subject to a Medicare audit, make sure to do your due diligence in research before selecting an attorney. Your business is at risk, so it is crucial that your representation has experience and a history of success in this field.
Should you brush up on intelligence questions before an auditor visit?
You should brush up on answers to questions that you may be asked before the auditors visit. However, remember that this isn’t an intelligence test. Your employees will need to answer questions truthfully.
What Are Recovery Audit Contractor (RAC) Audits?
- Also known as a Medicare audit or a MAC audit, the Recovery Audits Contract (RAC)program is an aggressive campaign seeking reimbursement from healthcare service providers. These audits have become increasingly frequent over the past few years, and they will continue to for the foreseeable future. Whenever a healthcare facility gets hit with a Recovery Audit Contractor prog…
A Quick History
- The Medicare Recovery Audit Contractor program started in 2005 and was created as part of the Medicare Integrity Program from the Centers for Medicare and Medicaid Services (CMS). The objective of this program is to discover any improper payments that are charged for uncovered services. These include services that are deemed “not reasonably necessary.” The RAC audits al…
Remediation and Protection Procedures
- These days, healthcare service providers have become increasingly concerned about Medicare RAC audits. It’s easy to see why. Some hospitals have millions of dollars’ worth of claims, and all of these could suddenly go under appeal at any second. Hospitals already face having to reduce profit margins due to low reimbursement rates and higher costs. An RAC audit could have devas…
Compliance
- Medicare already has specific guidance in place for every healthcare provider and physician. Outside of that, it won’t provide any more guidance. To keep yourself in the best position possible, your practice needs to have a system that monitors coding and documentation for compliance. You will also need to have an effective framework for keeping track of all RAC requests. Of cour…
RAC Fees
- The fees for RAC audits are generally based on contingency, as explained earlier. This provides an additional incentive for auditors to find errors. Note that while these fees are contingency-based, they will depend on contract negotiations directly with the CMS. The fee structure generally follows: Region A:12.45% States:Connecticut, Delaware, District of Columbia, Maine, Maryland, …
Conclusion
- If you are subject to a RAC audit, make sure to make an informed decision selecting an attorney. You’ll need an experienced team well versed in this subject to effectively refute fraud claims, especially in complex RAC audits.