Get the Scoop on RAC Healthcare Audit Issues

There's some changes that CMS has made relative to the full scale nationwide RAC program. Now, by the time they really get geared up which is going to be this small, they're going to have a good two-year look back and then it's not going to take very long before they get to a full three-year look back.

Also, they're allowed to review current fiscal year medical coding and billing claims, which is good because if they come in and review a current claim and they say, “No, it shouldn't have an inpatient admission. We want our money back” at least you have the opportunity to refile, okay? So, that's good. And they're using certified coders.

Medical Record Limits

Now, medical record limits. How many medical records can they request? Well, there seems to be some confusion in this area. As mentioned by our expert in a medical billing trainingevent, RACs also using the MPIs and that's the provider identifiers in order to determine the number of records. And of course, none of us even thought about the fact that they would ever use the MPIs and the subunits in order to determine the number of medical records they're going to request. So this is kind of a mess.

Contingency fees will be returned at any level of appeal. And the RACs are supposed to have web-based programs so that - and these for the most part are up although they're not completely done. But you should start looking for issues. In other words, the RACs will need to put out on their websites the issues they're going to look at.

Now, whenever they got an issue out there, you want to take that issue and ask yourself, does this apply to us? Have we done a little internal healthcare audit? Are we doing this correctly, et cetera. So look for those issues.

Extrapolation is available. And extrapolation is a statistically formal process. And you need to have a mathematician or statistician take a look at the way in which they are doing it.

Also on the appeals process they did change a word. But the zero level appeal used to be called a rebuttal. In other words, you would get a letter from the RAC indicating that an overpayment had occurred and then you would rebut that directly back to the RAC as per healthcare rules. We'll they're calling that a discussion. Now it's going to be called a discussion, everyone.

Actually, or the most part you will skip the zero level because if the RAC thinks you got an overpayment, then they are going to change their stance unless you really have something that you can give to them that would cause them to change their stance.

Watch for outreach activities

The RACs are supposed to be reaching out to you to let you know what's going on, how they're going to do it, how the contacts are. Now, the information we've got on some of these outreach programs is not very good, guys. It's been very limited. And we'll have to wait and see how that's going to play out.

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