What is a CMS RAC audit?
What does a Recovery Audit Contractor (RAC) do? RAC’s review claims on a post-payment basis. The RAC’s detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.
How far back can Medicare RAC audits go?
three years
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.
What triggers a RAC audit?
RAC audits—which may be triggered by an innocent documentation error—are not one-time or intermittent reviews. They are part of a systematic and concurrent operating process created to ensure compliance with Medicare’s clinical payment criteria and documentation and billing requirements.
What is the RAC process?
First, the RAC identifies a risk pool of claims. Second, the RAC requests medical records from the provider. Once the records are received by the RAC, they will review the claim and medical records. Based on the review, the RAC will make a determination: overpayment, underpayment or correct payment.
What triggers a Upic audit?
UPIC’s are private sector organizations that review Medicare claims in order to assist the government in recovering overpayments to healthcare providers. UPIC audits are often generated through data analysis or by review of consumer complaints and most often target specific healthcare providers.
Are RAC audits random?
Look-back Period, Required Response Time and Appeals A Complex audit is a comprehensive review of charts and claims, while an automated audit is more of a random spot check of files. For each type, the “look-back” period is up to three (3) years of claims records.
How can we avoid RAC audit?
Avoid the Overuse of Levels 4 and 5 in E/M Codes Just as your billing department needs to avoid under-coding for E/M visits, they need to avoid overuse of levels 4 and 5 as well. Both mistakes will cost your practice revenue, and in the case of over-use, could lead to having to reimburse payers for over payment.
What is the RAC appeal process?
There are three levels of appeal: Level I: Request for Reconsideration; Level II: Request for CMS Hearing Official Review; and Level III: Request for CMS Administrator Review. This page will assist you in understanding this process and how to file an appeal.
What is a UPIC in Medicare?
UPICs were created to perform program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching.
What is a Medicare Upic audit?
Unified Program Integrity Contractors (UPIC) Audits Goal The Centers for Medicare and Medicaid Services (CMS) created the UPIC audits to identify and stop fraud and abuse in Medicare and Medicaid. The main goal of UPIC is to help CMS: Find fraud, abuse, and waste. Perform regional Medicare and Medicaid data analysis.
How are RAC audits paid?
RACs are paid on a contingency fee basis, which means they are reimbursed based on a percentage of the improper payments they find or collect. The amount of the contingency fee is based on the amount of money from, or reimbursed to, providers.
What does the Centers for Medicare and Medicaid (CMS) do?
The CMS oversees programs including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the state and federal health insurance marketplaces. CMS collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the healthcare system.
What does CMS stand for in government contracting?
Contracting With CMS – General Information The Centers for Medicare & Medicaid Services (CMS) provides direction and technical guidance for the administration of the Federal effort to plan, develop, manage and evaluate health care financing programs and policies.
Where can I find contact information for CMS Regional Office?
Social Security: 800-772-1213; Social Security; Contact information for CMS Regional Office. Provides contact information for your CMS Regional Office, and s pecific program issue contacts are also available as PDF download. CMS Regional Offices; CMS Baltimore Headquarters Telephone Numbers. Toll-Free: 877-267-2323 (Employee directory available)
Why work at CMS?
Our mission is clear – putting patients first. And our ability to manage the Medicare, Medicaid, and Health Insurance Marketplace programs depends on our dedicated staff of public servants. So whether you’re tech savvy, health focused, numbers driven, or anywhere in between – explore what CMS has to offer for you.