| There are only three scenarios in which a | | | | your practice is making mistakes (i.e. medical |
| Medicare Recovery Audit Contractor can utilize an | | | | necessity, duplicate services billed, etc.). Wen you |
| automated review to determine if a claim paid to | | | | conduct your internal pre-audit, its a good idea to |
| your practice was an overpayment. If you know | | | | look at billing data that falls in the same date |
| what these three scenarios are, your practice can | | | | range mentioned above as this is what the RACs |
| better predict the likelihood of Medicare RAC | | | | will be reviewing with their data mining software. |
| auditors sending a demand letter to your mailbox. | | | | To get an idea of how to conduct your internal |
| According to the Centers for Medicare and | | | | audit and what to look for, review the |
| Medicaid (CMS), a Recovery Audit Contractor | | | | Department of Health and Human Services (HHS) |
| may demand repayment of a claim without | | | | Office of the Inspector General (OIG) Work Plan |
| reviewing your medical records in the following | | | | and review the RACs website that is covering |
| situations: | | | | your geographic region. |
| | | | Hiring a third party audit firm may be a good idea |
| 1. A statute, regulation, or national or local | | | | if you do not have staff on hand that have the |
| coverage determination rules reimbursement for a | | | | credentials to conduct a thorough audit. The cost |
| service will always be an overpayment. | | | | of hiring a third party will be more than worth the |
| 2. The service is found to be a medically | | | | benefit of avoiding any serious fines or penalties |
| unnecessary service. | | | | as a result of RACs finding overpayments in your |
| 3. Your practice fails to respond timely to a | | | | practice. The ability to receive qualified training is |
| demand letter requesting medical records. | | | | also critical so that any errors or mistakes |
| With these three scenarios being known, you can | | | | identified can be corrected moving forward. |
| perform a pre-audit within your practice to | | | | If a RAC does request medial records from your |
| identify any areas of risk that might throw up a | | | | practice and you fail to respond within the |
| red flag if an automated review is performed on | | | | required time frame, the claims in question will |
| your data The key to remember is that CMS has | | | | automatically be classified as improperly paid and |
| sent Medicare claims data from October 2007 to | | | | you'll receive a demand letter for the full amount |
| February 2009 to the Recovery Audit Contractor | | | | of the claim. During the initial three year |
| (RAC) that is covering your region for data mining | | | | demonstration conducted by CMS, "a significant |
| purposes. The RACs have the ability to analyze | | | | amount" was collected by RAC just for |
| this data and look for overpayments without | | | | non-response from the organization being audited. |
| requesting any medical records from your | | | | If during an automated data review a RAC finds |
| practice. | | | | an underpayment, they will notify your Medicare |
| It's a good idea for your practice to be prepared | | | | Part B carrier and if your carrier agrees with the |
| and identify any overpayments before a RAC | | | | finding, it will correct the claim and issue you an |
| identifies them and sends you a demand letter. A | | | | additional payment. |
| pre-audit will help you identify any areas where | | | | |