RACs: Proven Tips and Tactics to Reduce Your Audit Risks and Appeal Payment Denials

Table of Contents

CMS Initiatives and Guidance

• CMS Switches Gears, Approves RAC Audits During Blackout Periods
• CMS: Sending Records Electronically Will Make Audits More Bearable
• CMS Nearly Doubles Investment in RACs, Has Method to Win More Provider Appeals
• New RAC Statement of Work Gives and Takes; Less Burden Promised
• Final Rule on Medicaid RACs Covers Fraud Referrals, Coordination
• In First RAC Report to Congress, CMS Says Contractor Validates RACs

High-Risk and Target Areas

• RAC Overpayment Identification Is Picking Up Steam; Hospitals Improve Oversight
• Scrutiny of Medical Necessity Intensifies, but Gray Areas Persist
• Kidney Injury, Urinary Surgery Are Targets as RACs Amp Up Medical-Necessity Reviews
• CMS: MS-DRGs Shouldn’t Be Coded Until MD Documentation Is Done
• Hospitals Face Scrutiny in 16 Risk Areas in OIG’s Medicare Compliance Reviews
• Top 10 Upcoming Compliance Challenges: Putting Your Money Where Your Risks Are
• RACs Audit Transfers to Post-Acute Care; Refunds to Hospitals May Be a Result
• Health System Reaches Settlement After Assigning the Wrong DRGs
• Some Compliance Programs May Fail to Reduce the Risks Of False Claims
• Medicare Auditors Target Place-of-Service Codes; Provider-Based Status Is at Risk
• MS-DRGs Targeted in RAC Prepayment Demo Raise Red Flags Despite the Delay

Facing RACs: Strategies for Success

• Greater Scrutiny, Use of PEPPER Data Will Reduce RAC Risks
• RAC Extrapolation May Not Be Too Far Off; Process Requires Hospital Oversight
• RAC Letters Are Shifted to MACs in Bid to Solve Lateness Problem
• Role of Prepayment Audits, Documentation Grow as RAC And RAC-Like Audits Multiply

Denials and Appeals

• RAC Medical Necessity Audits Accelerate, But Hospitals Say Some Miss the Boat
• MACs May Change Their Mind on Closed Cases, Sit on Money Too Long Post-Appeal
• CMS Opens Door to Rebilling Inpatient Denials; RACs to Start Prepayment Reviews

Written By

This book was written by the editorial staff of AIS.

Written For

Compliance officers; attorneys; and financial and operations executives at

• Hospitals
• Health systems
• Medical group practices
• Consulting firms
• Law offices

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• Read the Introduction to this Report