RAC Audit Checklist

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

  • Inpatient
  • Outpatient
  • Therapy
  • Surgical procedures
  • Incomplete documentation and/or interpretation
  • Evaluation and management (E/M) levels
  • DRG
  • Coding errors
  • Medical necessity
  • Lab, radiology
  • Infusion and transfusion
  • Social worker services in facilities
  • Place of service errors
  • Incident-to-error
  • 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.