CMS and Medicare RAC audits for healthcare have not been instituted fully in a national phase-in policy by provider type, but the process is in the works. All provider types are available for RAC review once provider outreach has taken place in the state. Any reviews about medical billing completed by the RAC must have prior approval by RAC Audit Healthcare with RAC audits and posted to the RAC websites.
After spending the last 30 years in collecting and analyzing patient treatment outcomes data from internal programs, RAC Audit Healthcare and RAC Audit Career Services have committed extraordinary resources to impose evidence-based coverage policies, thereby preventing Medicare and Medicaid fraud through Medicare RAC audits. This emerging career field is an ideal choice for new healthcare professional.
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Medicare and Medicaid Audits
Some examples of ongoing Medicare RAC audits include Medicare One PI system and Medicaid Integrity Contractor audits that are designed to find overpayments to healthcare providers and to look at the potential for fraud in the Medicare billing and insurance billing sectors. New careers in the field include general medical coders, hospital billing, provider payment positions and auditors. The implementation of Medicare RAC audits for all healthcare providers will be staggered, once regional RAC auditing is implemented in each state. These Medicare RAC audits are the first real substantial effort to push hospitals, physicians, insurance companies, and other healthcare providers to conform to new Medicare RAC Audit guidelines, and the audits are also intended to reform the clinical practice of medicine, and the overall medical billing, coding, insurance and transcription services.
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New Criteria for Medicare and Medicaid Reimbursements
Both Medicare, as well as Medicaid, have started adopting clearly defined coverage criteria for medical services reimbursement. Of course, as the new healthcare law is implemented, further changes to the auditing is likely, but will most likely be evidence-based relying on coverage policies, verifying supporting medical documentation, replacing QIOs with RACs, defining clinical payments criteria, looking at standard treatments and outcomes, and insurance claims payment levels. RAC Audit Healthcare has also started hiring independent medical collection agencies, namely the RACs, to lead the way in the implementation of new procedures. This, of course, is a potentially fast-growing job sector for new billing coders and auditors.
Also, in addition to law enforcement efforts in order to stop Medicare and Medicaid fraud, RAC Audit Healthcare calculated billions of dollars in overpayments for patient medical services that should be automatically identified with the new, national Medicare RAC audits.
RAC Audit Healthcare and Medicare RAC auditing may at times reject patient services in part or in full. Although for providers, taking a rejection as a complete rejection of all services is premature as many services rendered will still be valid despite, say, an unnecessary admissions to a hospital or longer than usual stay in a hospital. Individual services, treatments, procedures, labs or other testing may still be covered, so, it essential or healthcare providers to submit for reimbursement on all procedures and services. Claims will not be dismissed automatically, but will require supporting documentation for reimbursement.