Healthcare News & Insights

Medicare audits coming back: What CMS is looking for

Healthcare providers need to get ready — the recovery audit contract (RAC) program is being revived. 

454952685Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced that it would put a hold on its recovery audit program. It’s plan was to let its current RACs expire in June, and in the meantime work through its massive backlog of appeals.

The Department of Health and Human Services (HHS) is supposed to make decisions on appeals within 90 days. However, there are so many appeals in the system that some facilities could be waiting five years for a decision — cutting off a major source of revenue.

Now, CMS is bringing back RACs, though at limited capacity, as Modern Healthcare reports.

Limited return

Since CMS hasn’t licensed any new contractors, its plan is to modify current contracts so that auditors can continue some reviews.

The good news: A majority of the reviews will be done automatically.

The bad news: There are still going to be some complex reviews based on certain topics CMS has flagged as high risk for fraud.

This time around RACs will be looking at claims related to:

  • spinal transfusions
  • outpatient therapy services
  • durable medical equipment
  • prosthetics
  • cosmetic procedures, and
  • orthotics and supplies.

Despite the audits starting again, it seems that the appeals process is still shut down for the time being.

Since appeals are still a slow and costly process, your best bet is to bump up your compliance efforts. That way you pass your audit the first time around.

As part of this effort, your facility should consider performing self-audits of your claims to make sure it’s staying compliant, especially for services identified for new RAC reviews.

Depending on when your last complete self-audit was, it may be worthwhile to conduct a more thorough claims review. CMS is looking to step up fraud prevention in all areas, using its new fraud prevention system to analyze claims for compliance and potential fraud patterns in billing.

So if you do conduct self-audits, be sure to keep detailed records of what claims and services were reviewed  and what the audit process entailed. That way if CMS’ system believes your billing may follow a pattern showing fraud, your facility will be in a better position to defend its billing process.

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