Published 1/1/2020 Recovery audit contractors (RACs) are responsible for identifying improper payments made on claims of health care services provided to Medicare beneficiaries. The RAC program was established by Section 302 of the Tax Relief and Health Care Act of 2006.
What is the Medicare Recovery Audit Contractor program?
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.
What is a Medicare fee for service recovery audit?
The mission of the Centers for Medicare and Medicaid Services (CMS) Medicare Fee for Service (FFS) Recovery Audit Program is to identify and correct improper payments made on claims for healthcare services provided to Medicare beneficiaries.
What is a Medicare RAC Audit Contractor?
Whenever a healthcare facility gets hit with a Recovery Audit Contractor program, they could be under significant threat. The Medicare RAC audit examines pretty much everything about your practice—including your finances. If the audit finds any discrepancy, your practice and reputation could very well be on the line.
What does the recovery auditor do?
The Recovery Auditor detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments: Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected.
What do recovery audit contractors do?
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 is the goal of a Recovery Audit Contractor program quizlet?
What is the goal of the Recovery Audit Program? Identify and correct improper payments made on claims of services provided to Medicare beneficiaries.
What will the Medicare auditor check during the audit?
your investigation should determine whether the chart pro p e rly documents the services and whether the services were properly coded on the claim form. Review the claims you submitted as well as the payment history and explanation of benefits for the audited services.
What is the goal of the recovery audit program?
The goal of the Recovery Audit program is to identify and reduce improper payments made on claims for services provided to Medicare beneficiaries. All providers, including home health and hospice providers, may be subject to claims review by a RAC.
Which of the following is a responsibility of Medicaid Integrity Contractors MICS )?
CMS has broad responsibilities under the Medicaid Integrity Program to: Hire contractors to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues.
Why was the National Recovery Audit Program RAC established and implemented quizlet?
The purpose of National Recovery Audit Program is to prevent future improper payments. The program recovers improper payments on behalf of CMS. In exchange for identifying improper payments, the RACs receive a contingency fee for each recovered improper payment.
Who audits Medicare claims?
One of the primary tasks of the SMRCs is to conduct nationwide medical review as directed by CMS. SMRCs will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment and billing guidelines.
What are the types of Medicare audits?
There are mainly three types of audits — Recovery Audit Contractor (RAC) audits, Certified Error Rate Testing (CERT) audits and Probe audits. Mistakes in medical documentation, coding and billing can rouse Medicare's suspicion during audits, which can lead to claim denials.
What is a Medicare OIG audit?
Under this authority, OIG conducts audits of internal CMS activities, as well as activities performed by CMS grantees and contractors. These audits are intended to provide independent assessments of CMS programs and operations and to help promote economy and efficiency.
What is a Medicare administrative contractor?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
How do I respond to a Medicare audit?
How to Respond to a Medicare AuditTake all correspondence from Medicare, or the Medicare contractor, seriously.Read the audit letter carefully and provide all the information requested in the letter.Include a copy of the complete record and not just those from the dates of service requested in the audit letter.More items...
What does the Zone Program Integrity Contractors do?
The Zoned Program Integrity Contractor (ZPIC ) for Zone 4 is used to collect and analyze operational data from Medicare contractors across the country for use in detecting and preventing fraud, waste and abuse (FWA) as well as abuses within the Medicare Part A, B and D programs and the Medicaid and Hospice programs.
How are RACs paid for their services?
RACs are paid on a contingency fee basis, which means they are reimbursed based on a percentage of the improper payments they find or collect. The amount of the contingency fee is based on the amount of money from, or reimbursed to, providers.
Which act expanded the project recovery Medicare overpayments and identify underpayments to all 50 states?
Section 302 of the Tax Relief and Health Care Act of 2006 requires the Secretary of the Department of Health and Human Services to utilize Recovery Auditors under the Medicare Integrity Program to identify underpayments and overpayments and recoup overpayments under the Medicare program associated with services for ...
What is Recovery Audit Contractor (RAC) Audit?
As a combined effort to fight fraud, waste, and abuse in the Medicare program, Recovery Audit Contractor (RAC) audit was in place from January 1, 2010. The goal of the recovery audit contractor program is to identify improper payments made on claims for services provided to Medicare beneficiaries.
The goal of the Recovery Audit Contractor (RAC)
As discussed above, RAC contractors are tasked with identifying improper payments made on claims of health care services provided to Medicare beneficiaries. Under most circumstances, the RAC will request medical records from the provider to determine whether overpayment and/or underpayment have occurred. Payments will be deemed improper when:
Filing an Appeal
The RAC Contractor has the ability to perform extrapolation based on improper payments identified during a review. If you receive an overpayment demand letter, and if you believe the request for overpayment is unjustified, you must file an appeal.
To summarize
Outsourcing Medical billing is complex, and your staff must be knowledgeable about many areas pertaining to billing and reimbursement. You have to establish compliance and practice standards and need to conduct internal monitoring and auditing to evaluate adherence.
2005-2010: A history of Recovery Audit Contractors
Before moving forward, let’s take a moment to look back at the history of audits and denials to help understand where we are today. In 2005, Congress authorized the Centers for Medicare & Medicaid Services (CMS) to initiate the Recovery Audit Contractor (RAC, now RA) program.
The problem with Recovery Audit Contractors
When the RAC program was rolled out nationwide, it presented three key challenges that providers found difficult to overcome.
2010-2018: A slow-down on RAC audits
With all these issues causing providers grief in the RAC audit process, change was inevitable. One of the most impactful changes came slowly over the years, as providers began to notice that in comparison to the 2000s, CMS became much less aggressive in conducting RAC audits.
2018-Present: A new era of RAC audits
CMS re-launched the RAC audit program in 2018 with new rules and guidelines for audits. The biggest change was to reduce the number of documents a Recovery Audit Contractor could request in a certain time frame. This meant fewer audits with fewer document requests per audit.
Are Recovery Audit Contractors still relevant today?
Short answer: yes. Recovery Audit Contractors are still relevant and worth your time to protect reimbursement dollars. RACs cannot be ignored or cast aside.
What is Medicare Recovery Audit Contractor?
Any medical practice submitting claims to a government program can be subject to a Medicare Recovery Audit Contractor (RAC) audit. RAC audits—which may be triggered by an innocent documentation error—are not one-time or intermittent reviews. They are part of a systematic and concurrent operating process created to ensure compliance ...
How does CMS prevent improper payments?
The RACs detect and correct past improper payments so that CMS can implement actions to prevent future improper payments. CMS anticipates the following benefits: 1 Providers can avoid submitting claims that do not comply with Medicare rules. 2 CMS can lower its payment error rate. 3 Taxpayers and future Medicare beneficiaries are protected.
How long does it take to pay a recoupment check?
If a recoupment demand is issued and you agree with it, you have the choice of paying by check within 30 days, allowing recoupment from future payments, or requesting an extended payment plan. If you do not agree with the audit findings, there is an appeal process.
What is OIG billing?
The OIG is studying the link between electronic health record (EHR) systems and coding for billing . There is a concern that some EHR systems may generate upcoded billing through automatically generated detailed patient histories, cloning (when examination findings are copied and pasted), and templates filled in to reflect a more thorough or complex examination/visit. Review these issues with your EHR vendor and determine if your EHR program has the potential to automatically upcode billing based on EHR documentation.
What is Medicare Recovery Audit Contractor?
These include services that are deemed “not reasonably necessary.”
What are the two types of Medicare RAC audits?
Types of RAC Audits. Generally, there are two types of Medicare RAC audits – the automated audits and complex audits.
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 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.
Is CMS still enforcing Medicare RAC audits?
All in all, the CMS is expected to continue enforcing standards for payments and Medicare RAC audits. Healthcare service providers will also be looking to minimize the risk that the Medicare recovery audit contractor program can have on them, both from a financial and reputational perspective.
What is CPI in Medicare?
T/F: The Center for Program Integrity (CPI) was created in 2010 and separated the Medicare and Medicaid program integrity groups under two management structures to strengthen and better coordinate existing activities and to detect fraud, waste, and abuse. false.
Does Medicare pay to one home health agency?
T/F: Medicare makes payments to one home health agency under the consolidated billing process. With that in mind, it is the responsibility of the home health agency to determine if any other services or providers are in a patients home prior to starting care with that patient. True.
What Are Recovery Audit Contractor (RAC) Audits?
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 necessa...
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.