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How has the Medicare Recovery Audit Contractor Program changed?
CMS will now restrict the Recovery Audit Contractor (RAC) programs look-back period to six months from the date of service for patient status reviews. However, hospitals must submit an inpatient claim within three months of the date of service for this look-back restriction to take effect.
What is the purpose of a recovery audit contractor?
RAC is the abbreviation for recovery audit contractor. The purpose of an RAC is to identify overpayments and underpayments made by the Medicare program under Part A and Part B. The RACs are also responsible for the recoupment of overpayments made to providers.
What triggers RAC audits at a facility?
Automated RAC Audits These audits are typically used when a clear policy or coding rule has been violated. For example, if a provider bill for a service that is not covered by Medicare, an automated audit would identify this error.
What is the goal of the recovery audit contractor program?
The goal of the RAC program, as required by the federal law and regulations noted above, is to correct improper payments, including both underpayments and overpayments, and guard against fraud, waste, and abuse within Medicaid programs.
What triggers a RAC audit?
RAC auditswhich may be triggered by an innocent documentation errorare not one-time or intermittent reviews. They are part of a systematic and concurrent operating process created to ensure compliance with Medicares clinical payment criteria and documentation and billing requirements.
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First, the RAC identifies a risk pool of claims. Second, the RAC requests medical records from the provider. Once the records are received by the RAC, they will review the claim and medical records. Based on the review, the RAC will make a determination: overpayment, underpayment or correct payment.
What triggers a Medicaid audit?
Unusual Billing Patterns: Billing practices that deviate significantly from the norm can trigger an audit. This might include billing for services rendered at unusual times, such as frequent billing for after-hours services that do not match the providers typical hours of operation.
What are RAC audits looking for?
The RACs are charged with finding improper paymentswhich could be either an underpayment or an overpayment. The RACs use proprietary software programs to identify potential payment errors in areas such as duplicate payments, fiscal intermediaries mistakes, medical necessity, and coding.
Related links
medicare advantage
HHS, the Comptroller General or their designees have the right to audit, evaluate and inspect any pertinent information of Practitioner including books,
Dr. Ann Sheehy comments on Recovery Audit Contractors
Feb 13, 2019 Ann Sheehy, MD, MS, associate professor and head, Hospital Medicine, opposes the idea of RACs taking on additional oversight of hospital claims
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