CMS RAC Audit Changes for the Healthcare Sector

In an attempt to move-the-bar, medical records and collection on overpayments to CMS RAC Audit billers,CMS RAC Audit (Centers for Medicare Services) is taking extraordinary steps to accelerate the implementation of evidence-based health care, thus easing the load of a stressed national budget regarding Medicare payments. After spending the period of past 30 years in collecting and analyzing patient encounter outcomes data from internal programs, CMS RAC Audit services have committed resources to impose evidence-based coverage policies, thereby preventing Medicare fraud. All provider types are available for RAC review, once provider outreach is implemented in each state. Any reviews about medical billing completed by the RAC have to have prior authorization by CMS RAC Audit and posted to the RAC websites. The RAC websites can be found in the RAC contact information document provided in the download section.

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Medicare One PI system and Medicaid Integrity Contractor audits are just some examples of the ongoing CMS RAC auditing for medical companies, hospital billing, and plans focused on provider payments. However, CMS RAC Audit is adopting RAC audits as the first real substantial effort to push hospitals, physicians, and other healthcare providers billing the government through CMS RAC towards a path of reforming the clinical practices of medicine, medical billing, transcription and general auditing services.

Importance of the CMS RAC Audit

For the past 20 years, every hospital department administrator, compliance officers, as well as case CMS RAC Audit coding career management professionals have kept a similar charge – which stated is “If it’s not documented, it’s not done.” Both Medicare, as well as Medicaid, have started adopting clearly defined coverage criteria, evidence-based coverage policies, verifying supporting medical documentation, replacing QIOs with RACs, defining clinical payment criteria, forcing the issue of evidence-based outcomes, and insuring claim payment levels.

Hence, CMS RAC Audit has also started hiring independent medical collection agencies i.e. Recovery Audit Contractors or RACs to lead the way; and they are paying approx 9% – 12.5% as a contingency fee to guarantee the desired outcomes for general auditing.

Claims Adjustment and Overpayment Recuperation through Audits

CMS RAC Audit, or the Centers for Medicare and Medicaid Services, recently undertook the RAC demonstration project in states including Florida, New York, and California, while preparing for a nationwide rollout. In addition to the first $36.2M in FY 2005, the RAC audits recuperated $332.9M in FY 2006 and an astounding $610.9M in FY 2007 in overpayments to providers in the demonstration states. Also in addition to law enforcement efforts in order to stop Medicare fraud, CMS RAC AUDIT calculated approximately billions of dollars in overpayments for patient services, which will be automatically identified with the national RAC audit focus.

Inpatient Rejections May Allow Partial Reimbursements

CMS RAC Audit is asked often about other claim types that may be influenced by a full inpatient rejection, and if the RACs in any case will deny other claim types that are associated with the inpatient stay like physician evaluation and management services. At this time, RAC will not automatically deny all the claims that are associated with a full inpatient rejection. However, these claims could be reviewed individually, and there may be a need to adjust fully/partially the entire claims for that patient based on the submitted documentation.