Medicare fraud is big business, but while only a few profit from intentional malfeasance, the Centers for Medicare & Medicaid Services is now taking a closer look at everyone. The Medicare Recovery Audit Contractor Program, already infamously known as the RAC, swings into full operation in 2010 and every healthcare provider that receives payment under any of the Medicare fee-for-service payment systems will be subject to RAC scrutiny. And scrutinize, they will...Instead of developing another bureaucracy, the government has turned the job of auditing over to outside firms whose payment will be based exclusively on finder fees for recouping improper payments. There will be little tolerance for poor record keeping or gray areas of coding. Written by medical billing guru and Lean accounting expert, Duane Abbey, The Medicare Recovery Audit Contractor Program: A Survival Guide for Healthcare Providers explains all that is required to prepare and successfully defend against inappropriate RAC audit recoveries.
Using the same succinct style that always makes his writing so accessible, Abbey illustrates his lessons with simple case studies placed in the context of a fictitious community whose population is served by a hospital, clinics, a nursing facility, and other providers all seeking to maintain compliance and profitability. In discussing RAC guidelines, this resource - Shows how to identify overpayment areas and associated compliance issues Details a systematic problem-solving process relative to RAC processes Addresses resource requirements including new personnel, such as RAC specialists Includes planning models for developing compliance departments Provides an extensive glossary to make sense of medical billing's alphabet soup of acronyms While the book works well as a stand-alone reference for those seeking advice on RAC audits, readers will also discover that this volume extends the lesson of Abbey's classic Compliance for Coding, Billing & Reimbursement, Second Edition , making this book a natural companion for those wanting to fully explore the role of compliance and Lean accounting in medical billing.
Acronym Listing Chapter 1 Introduction Synopsis Conventions Used throughout the Book Chapter 2 Purpose, Structure, and Intent of the RAC Audit Program Introduction RAC Demonstration Project Selection and Utilization of RACs CMS and the RAC Operations Payment of the RACs Summary and Conclusion Chapter 3 RAC, OIG, and Medicare Audits Introduction General Categories of Audits Medicare Audits OIG and DOJ Audits Medicare CERT Program OIG Guidance: Federal Register RAC Audits What Happened to the Underpayments? CMS's Approach for the RACs Summary and Conclusion Chapter 4 Brief Review of Healthcare Payment and Payment Systems Introduction Claims Adjudication Requirements Covered Individual/Covered Services Proper Orders with Appropriate Diagnostic Justification Qualified Facility or Practitioner Appropriate Documentation Medicare Billing Privileges Correct Claim, Filed Timely Medicare Payment Systems Medicare Fee Schedules Medicare Prospective Payment Systems Medicare Payment System Interfaces Summary and Conclusion Chapter 5 RAC Audit Issues Introduction Underlying Compliance Areas Medical Necessity Payment System Interfaces Inadequate Guidance Confusing Guidance Sample Problem Areas by Provider Type Hospitals Critical Access Hospitals Physicians and Clinics Other Healthcare Providers Summary and Future Issues Chapter 6 RAC Processes Introduction Problem Identification, Data Mining, and Probe Audits Automated Reviews Complex Reviews Extrapolation RAT-STATS Example Stratified Sampling Using Extrapolation in Reverse Summary and Conclusion Chapter 7 Understanding the RAC Appeals Process Introduction Appeals Process RAC Discussion Request for Redetermination Reconsideration Administrative Law Judge Medicare Appeals Council Federal District Court Pursuing the Appeals Process Developing Organizational Resources Case Development Hierarchy of Medicare Guidance Clarifying Guidance Ambiguous Guidance Incorrect Guidance Requesting Guidance and the Federal Register Coding/Billing versus Adjudication/Payment Directives Inherent in the Payment System Interpretation of Guidance Other Issues MMA 2003 Protection Provisions Addressing Extrapolation Cases Summary and Conclusion Chapter 8 Meeting the RAC Audit Challenge Introduction Reviewing and Assessing Current CBR Compliance Program Adapting Your CBR Compliance Program Budgeting and Financial Impacts Internal RAC Program Training Summary and Conclusion