The American Health Information Management Association (AHIMA) has a useful checklist, listed below, for providers facing a RAC audit. MTBC is committed to assist providers during audits by providing useful reports that can be located on our Practice Management site.
A: Create a RAC team
- Senior leadership
- Finance/revenue cycle
- Clinical documentation management
- Health information management (operations, coding, and ROI)
- Case management/care coordination
- Corporate compliance
- Business office (operations, Medicare specialist, and denials management)
- Information technology (IT) support services
- Clinical departments (as needed)
- Legal (internal and external) medical management
B. Develop Departmental Policies and Procedures
- Identify primary POC (point of contact) and back-up.
- Know RAC contact numbers.
- Establish in-house contact numbers.
- Create job description for RAC coordinator.
- Maintain tracking system.
- Prepare extension request letter.
- Prepare appeal letters.
- Ensure payment for copies has been received.
C. Educate Key Players Through Team Meetings
- Know the rules for RAC.
- Know Medicare policies. (According to the RAC Statement of Work, the RAC shall not help providers with policies.)
- Know difference between automated and complex reviews. Develop proactive approach for education. (Perform a RAC audit before CMS performs a RAC audit.)
- Educate RAC team.
- Educate other personnel.
D. Attend Provider Outreach Sessions
Prior to entering state, all contractors are required to hold a meeting.
- Identify times and dates on CMS Web site (www.cms.hhs.gov/rac) or contractors Internet page. (They should notify you.)
E. Develop Tracking and Appeals Process
- Identify tracking system, database or file.
- Know five levels of appeal. (Get to know the RAC contact.)
- Develop cover letter for each level of appeal (form).
- Determine who will decide if appeal will be submitted.
- Determine who should submit the letter. Recovery Audit Contractor (RAC) Toolkit © 2009 AHIMA
F. Know Time Frames
- 45 Days: records not received within 45 days can be declared an overpayment with no appeal rights for provider
- 15 Days: discussion period for determination
- 3-Year: look-back period from October 1, 2007
- August 2009 RAC audit activity begins
- 30 Day: write check to avoid interest
- 41 Day: Recoupment Period
G. Identify Eligibility For RAC Possibilities
- Surgical procedures
- Incomplete documentation and/or interpretation
- Evaluation and management (E/M) levels
- Coding errors
- Medical necessity
- Lab, radiology
- Infusion and transfusion
- Social worker services in facilities
- Place of service errors
- Stark violations
- Duplicate billing
- Debridement coding
- E/M utilizing modifier 24
- Pharmaceutical coding in physician offices
H. Know RAC Will Not Review a Claim that Has Been Previously Reviewed by Another
HHS Contractor Including:
- RACs can correct improper payments when the CMS FI or MAC did not apply the proper edits – NCCI, OCE, MUE, MCE.
- Carrier/FI/ MAC Medical Review (MR) (prepayment/post-payment claim review program)
- Comprehensive Error Rate Testing (CERT) Program (post-payment claim review program)
- Quality Improvement Organization (QIO)
- Zone Program Integrity Contractor (ZPIC) Former Program Safeguard Contractor
- Fraud investigations by the Department of Justice (DOJ), Office of Inspector
- General (OIG), or the state Attorney General (AG).
I. Know RAC Contractors Recovery Audit Contractor (RAC)
- Diversified Collection Services—Region A
- CGI—Region B
- Connolly Consulting—Region C
- Health Data Insights—Region D
J. Know RAC Subcontractors
- VIANT—Region C
- PRG-Schultz—Regions A, B, D
For detailed information about preparing for a RAC audit visit www.ahima.com.