How will the RAC Audit Work?

How with the RAC Audit Work?

RAC audits will NOT be performed by targeting certain practice groups (like hospitals, physicians or nursing homes), or even targeting certain specific "problem" providers. Instead, the RAC audits will review ALL of the claim records contained in the Medicare database. This means that all providers are equally at risk of audit. But, the RAC audits will not extend to all potential billing errors. Instead, the RACs are constrained to review only approved "Issues."

Currently, there are only six approved Issues, all of which appear to relate only to hospitals and physicians. But now that the mandated outreach has been conducted, new issues may be posted at any time. Certainly, speakers at the Ohio Health Care Association's conference alluded to the fact that a number of issues are making their way through the approval process.

These Issues will be listed on CMS' and the RAC contractor's website for each region. The Country was divided into four geographic regions - A, B, C & D -- and each area was assigned a specific RAC contractor. Ohio falls into RAC Area B, and CGI Federal is the assigned contractor. CGI's web address is contained below.

RAC Audits

There will be two types of audits, automated and complex. All audits will be Issue driven. The automated audit will use a computer program to review all claims in the Medicare claims data base from October 1, 2007 to the present (although there was an indication that claims are only fully updated through April, 2009). The computer program will then determine if any of the the identified Issues are found on any of the claims. (e.g., two codes that cannot co-exist = error). CGI will then attempt to identify the over- and underpayments made to providers as a result of those findings.

As with the automated review, complex review will start with a computer algorithmic analysis of the claims in the Medicare Database. And again, these reviews may only be conducted on approved Issues. But the complex review will require a review of medical records by CGI staff. If the provider is identified by the computer program, CGI will request additional documentation from the provider for review. The provider will then have 45 days (plus 10 for mailing) to submit the records. The RAC will have 60 days to review the records and make a determination.

In both kinds of review, there is an "informal period of discussion" where the provider can attempt to resolve the issue. If the matter is not resolved, the RAC will send the claim information to the fiscal intermediary to issue the adjustment in payment and the Remittance Advice to the provider. The normal appeals process follows (including the interest assessment on the 31st day, and the recoupment of any offset on the 41st day).

So what can a provider do? Read my next blog post on actions you can take to prepare for the audits!



Visit the CGI Website and study the issues for yourself:

http://racb.cgi.com/Issues.aspx?st=1