RAC Audits (Healthcare Providers)

Program Overview

The Recovery Audit Contractors (RAC) program was tested by the Center for Medicare/Medicaid System (CMS) in 2008 and rolled national during the 2nd half, 2009. The goal of the RAC Audit program is to identify improper payments made on claims of health care services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments.

Health Industry Regulatory Compliance Software Overpayments can occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Health care providers that might be reviewed include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers and any other provider or supplier that bills Medicare Parts A and B.

Recommended Actions By Providers

The CMS recommends that healthcare providers take pro-active steps including:

Identifying where improper payments have been persistent by reviewing the RACs’ Web-sites and identifying any patterns of denied claims within their own practice or facility.
Implementing procedures to promptly respond to RAC requests for medical records.
If the provider disagrees with the RAC determination, filing an appeal before the 120-day deadline.
Keeping track of denied claims and correcting these previous errors.
Determining what corrective actions need to be taken to ensure compliance with Medicare’s requirements and to avoid submitting incorrect claims in the future.

The DoubleCheck™ RAC Solution

On a broad perspective, DoubleCheck can help automate and unify any or all of an organization’s governance, risk, compliance and testing activities (GRC&Audit).

In this particular instance, it also includes automating the process of dealing with RAC Audits. Since Recovery Audit Contractors (RACs) can request up to 200 charts in successive 45 day periods, the task of managing the claims and multi-level appeals process can become overwhelming very quickly once it starts if you are not prepared or attempting to do the tracking manually.

With DoubleCheck, you will have the ability to manage to the CMS’s recommendations, including:

Automatically record RAC requests into software.
Track all RAC Audits from the receipt of the RAC request through the five levels of appeals process.
Escalate unresolved issues to higher level of management (up to Board of Directors) before appeals due dates.
Maintain all data for each request in one central location, including attachments and/or links to a central repository.
Settle appeals and move files to next level for control.
Provides dashboard and custom reporting for users and management.