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 is a Medicare Mac audit?
Jan 06, 2022 · Program Audits. The purpose of this web page is to increase transparency related to the Medicare Advantage and Prescription Drug Plan program audits and other various types of audits to help drive the industry towards improvements in the delivery of health care services in the Medicare Advantage and Prescription Drug program.
What is a CERT audit and how does it work?
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.
What happens if you do not comply with a Medicare audit?
Jan 06, 2015 · Medicare audits are conducted to make sure that the right beneficiary receives the right payment at the right time, and they are very important for healthcare providers who manage and process their Medicare claims.
How can I protect my practice from Medicare audits?
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. Whatever type of audit is conducted, they pose a serious threat to your …
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 happens when you get audited by Medicare?
Medicare audits are one of several things that can trigger a larger civil or criminal investigation by federal law enforcement. Usually, auditors con- clude that Medicare has made significant “over- payments”and demand that the audited physician return the money.
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
What is the purpose of a medical audit?
Medical auditing, like all audits, is the process of examining and reviewing documents and records to ensure accuracy. Medical auditing takes it a step further and examines medical records to ensure that doctors and medical facilities are in compliance with the rules and regulations of the medical field.
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 long do Medicare audits take?
After the provider is “targeted” using data analytics, the MAC performs up to three rounds of "probe and Educate." Each round takes about 90 days—30 days for MAC to review the claims, a few days to schedule an educational call, 45 days for providers to show improvement—and is centered around a one-on-one educational ...Jan 17, 2018
What will the Medicare auditor check during the audit?
In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.
What is an audit that takes place prior to billing?
The goal of a prospective audit is to catch any billing or coding errors before the claim is submitted. Retrospective audits involve reviewing claims that have already been submitted – and preferably adjudicated – as either paid, denied, or pending.Jun 13, 2021
How far 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
What is medical audit in healthcare?
"Medical Audit" is a planned programme which objectively monitors and evaluates the clinical performance of all practitioners, which identifies opportunities for improvement, and provides mechanism through which action is taken to make and sustain those improvements.
Why is audit important?
Why are Audit's important? An audit is important as it provides credibility to a set of financial statements and gives the shareholders confidence that the accounts are true and fair. It can also help to improve a company's internal controls and systems.
What are the advantages of medical audit?
It ensures proper payment collection by reducing and preventing improper payment collection methods. It encourages an accurate claim submission process. It helps to improve the quality of patient care. Reducing the chances of an external audit.Mar 22, 2020
What does a Recovery Audit Contractor (RAC) do?
RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.
What Topics do RAC's Review?
Stay in the know on proposed and approved topics that RAC's are able to review. These topics will be updated monthly on the RAC reviews topic page and include:
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.
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.
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.
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.
You might not be able to avoid a Medicare audit, but you can make sure you're totally prepared to face one. Click here to find out how
Medicare compliance rules for fully credentialed therapists can be more than a bit complicated, so it’s not...
1. There are three major audit-worthy red flags for physical therapists
As you know, Medicare policy is a web of super-confusing rules and regulations. But for PTs, the majority of audits result from one of the following triggers:
2. Sub-par documentation puts you at greater risk for an audit
In addition to the suspect practices listed above, the following mistakes could land you in hot water with Medicare:
3. Certain billing practices increase the likelihood of an audit
Even if your documentation is in tip-top shape, these billing no-nos could arouse Medicare’s suspicions:
4. There are measures you can take to protect your practice
When it comes to avoiding audits, knowledge is power, so make it your mission to educate yourself and your staff on Medicare’s Local and National Coverage Policies.
5. There are different kinds of audits
As this article explains, in 2010 President Obama announced an initiative to reduce the amount of money wasted on improper Medicare payments.
Can you alter a medical record?
Altering a medical record can be the basis for a fraud claim including criminal penalties. Make sure each page of the record is copied correctly and completely. If the copy of the record has missing information because it was cut off, the original needs to be recopied to ensure it includes all the information.
Can Medicare be audited?
The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited. Having too many claims for level five CPT codes might, for example, cause you to be audited.
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.
What do auditors request?
Auditors typically will request a list of every medication prescribed, dispensed, used, or billed for in your practice. They will follow up by asking for copies of all invoices for all drugs ordered, dispensed, or billed by your practice.
What does it mean when a letter comes across your office fax machine?
A letter comes across your office fax machine indicating that your practice has been scheduled for an audit and site visit from the Centers for Medicare and Medicaid Services, a Medicare administrative contractor, or a zone program integrity contractor the next morning at 8 a.m. Sound far-fetched? This exact scenario is likely if your practice is scheduled for such a visit from the federal government or a government contractor. The timing is intended to give you little chance to prepare.
How many people are required to visit a ZPIC site?
ZPIC site visits or audits typically include at least three people. When the auditors arrive, ask for their photographic identification and business cards. They all should have proper photographic identification from their company or agency. They should have business cards, but new employees and people in training sometimes do not. Write down the names, addresses, job titles, and telephone numbers of any person who does not have a business card. We have heard of (but have not confirmed) at least one instance where the inspected office did not verify auditors’ identities and failed the audit for lack of proper security under HIPAA and Medicare conditions of participation.
What happens if you don't update your physical address?
If you have not updated your physical address or you have an incorrect or incomplete address in the Provider Enrollment, Chain, and Ownership System (PECOS), the auditors may go to an invalid address or not be able to find you. Your Medicare billing privileges automatically could be terminated. If your address is incorrect, immediately change it or correct it in PECOS and the National Plan and Provider Enumeration System online.
Who is the communication liaison?
Usually, the communication liaison will be your office manager or practice manager - or you - because the person should know where to obtain all of the documents and information the auditors request. This person should stay with the auditors when they tour and inspect your office. Your attorney should accompany them as well, but he or she probably will not be able to answer most questions about your office or practice.
What to do if you don't know the answer to a question?
Before the site visit, instruct your staff members that if they don’t know the answer to a question, they simply should say so to the auditor when they are interviewed. Remind staff members that an audit is not an intelligence test and that staff members cannot fail the audit because they do not knowww an answer.
Do auditors want to interview?
Make sure it is clean and that the chairs are not damaged or torn. The auditors will want to interview virtually every one of your employees while they are there.
What is UPIC audit?
UPIC audits are often generated through data analysis or by review of consumer complaints, and most often target specific healthcare providers. Currently, telehealth claims are part of the UPIC targeted audits, as more and more providers have moved to a telehealth platform during the PHE. But in early review, it has been reported by CMS ...
What are the rules for telehealth?
The rules applicable to telehealth, supervision, inpatient rehabilitation facilities (IRFs), and nursing homes changed rapidly at the onset of the PHE, as well as “approved providers,” which can perform services that they may not have been authorized to perform before.
Who is Terry Fletcher?
Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.
