MEDICARE AUDITS – Recovery Audit Contractor

Medicare is a federal program that provides healthcare to the elderly and disabled, regardless of income. This is a great program for these individuals to get the medical attention they need. Meanwhile, healthcare providers are under scrutiny for claims submitted to Medicare. Sometime during President Obama’s first term, an anti-fraud task force was created in an effort to lower the cost of Medicare. The Recovery Audit Contractor (“RAC”) program is one of three main audit programs the Centers for Medicare/Medicaid Services (“CMS”) implemented to identify healthcare providers that potentially are over-billing CMS for services.

While this sounds like a great plan to ensure minimal fraud, are these audits too harsh on healthcare providers? The consequences can severely impact healthcare providers. A negative audit can cause added fees or reversal of Medicare payments.

The RAC program identifies and recovers improper Medicare payments that are paid out to healthcare providers under the fee-for-service (“FFS”) Medicare plans. RACs are supposed to detect and correct past improper payments for claims that do not comply with CMS rules and regulations. Any healthcare provider that bills FFS programs is subject to review.

RACs review selected claims on a post-payment basis as either an automated (no medical records required) or complex review (medical records required) basis. RACs cannot review claims paid prior to October 1, 2007 and they can only look back 3 years from the date the claim was paid.

At SAPG, we can help minimize the burden of audits on your office, prepare you for the investigation, and allow you to focus on what matters, YOUR patients. We can assist you through the audit process and assume all communication with auditors. SAPG will investigate and review the audits against the latest laws and CMS guidelines to ensure accuracy of the claims. We also help prevent audits or appeal audit decisions.