Who is Auditing?
- Fiscal Intermediaries
- Office of Inspector General (OIG)
- US Attorneys / State Prosecutors
What are RAC auditors looking for?
In addition to physically reviewing records, RACs also use electronic automated reviews searching for billing patterns that appear higher than the majority of providers in the community.
RAC auditors identify over payments for any of the following reasons:
- Payments that are made for services that do not meet Medicare’s medical necessity criteria. Payments that are made for services that were medically unnecessary or did not meet the Medicare. Medical necessity criteria for the setting where the service was rendered (e.g., a claim from a hospital for three colonoscopies for the same beneficiary on the same date of service, whereas only one colonoscopy per day is medically necessary; or physical therapy provided in the inpatient setting when the therapy could have been safely and effectively provided in the outpatient setting). 40% of errors found in initial phase = $391.3 million.
- Payments that are made for services that are incorrectly coded: (e.g., the provider submits a claim for a certain procedure, but the medical record indicates that a different procedure was actually performed). 35% of errors found in initial phase = $331.8 Million.
- Providers that fail to submit documentation when requested, or fail to submit enough documentation to support the claim. 8% of errors found in initial phase = $74.3 Million.
- Other reasons, such as basing claim payments on outdated fee schedules, or the provider is paid twice because duplicate claims were submitted. 17% of errors found in initial phase = $160.2 Million.
- RAC Audit Contractors are divided between 4 regions; A B, C & D. Visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-Contact-Information-042916.pdf for more information