The RAC process helps adults obtain a diploma or certificate of higher education by demonstrating mastery of their competencies. Throughout the process, specialists assess the tasks required for the recognition of competencies and provide personalized training when needed.
What does a Recovery Audit Contractor (RAC) do? RAC’s review claims on a post-payment basis. The RACs identify and correct past improper payments, allowing CMS and carriers, FIs and MACs to take action to prevent future improper payments.
The RAC, which reviews claims based on payment within the last three years, performs three types of reviews: Automated – no medical records required. Semi-Automated – Claims verification using data and potential human review of a medical record or other documentation. Complex – medical record required.
RAC Review Process
RACs review claims after payment and can look back three years from the date the claim was paid. There are two main types of verification – automated (no medical record required) and complex (medical record required).
What is the goal of the recovery audit program? Identify and correct improper payments made on Medicare beneficiary claims.
There are three appeal levels: Level I: Request for reconsideration; Stage II: Request for official review of the CMS hearing; and Stage III: Application for CMS admin verification. This page will help you understand this process and how to appeal.
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 Success Fee is based on the amount of money paid by or returned to the Providers.
RACs can look back three years from the date the claim was paid.
Through this communication, RACs are informing hospital providers of the results, overpayments or underpayments and due dates of complex or automated reviews. This letter states whether the overpayment (or underpayment) was identified through additional documentation request (complex verification) or through data analysis.
Technical denials can occur when an RAC denies a claim due to insufficient documentation – for example, when the RAC never receives the requested medical records from a provider. CMS considers technical rejections to be payment failures because it has paid for due diligence that cannot be documented, Levitt said.
Any vendor may appeal the initial decision of the recovery audit contractors, informally or formally. The informal process is to appeal directly to the contractor within 15 days of receiving notice to recover any overpayment from the RAC.
History of Part D RAC program
In 2005, CMS implemented the Medicare Recovery Audit Contractor (RAC) program as a demonstration program for Medicare Fee-for-Service (FFS) ; Medicare Part A and Part B. The pilot program successfully corrected more than $1.03 billion in improper Medicare payments.
What triggers a Medicare audit? A key factor that often triggers scrutiny is requiring reimbursement for a higher than usual frequency of services over a period of time compared to other healthcare professionals providing similar services. p>
The goal of the RAC was to identify claims that are most likely to involve improper payments.
The purpose of the National Recovery Audit Program is to prevent future improper payments. The program collects improper payments on behalf of CMS. In exchange for identifying fraudulent payments, RACs receive a success fee for each fraudulent payment recovered.
interrupted stay. NOTE: When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (before midnight on the third day), it is said to have an interrupted stay.
Stage III: Hearing before an administrative judge.
Providers have 60 days from receipt of the reconsideration decision to file a request for a hearing. A decision will be made within 90 days of receipt by the Administrative Judge Hearing Board.
There are two main bodies that perform external audits: commercial insurance companies and the US government. Many of these audits are performed by third parties.
RAC coordinators review medical bills in hospitals, doctor’s offices and other medical facilities and ensure that these facilities provide proper documentation and payments. If fraud or improper payments are discovered, notify the appropriate parties or coordinate objection procedures for those disputing payments.
RAC is an acronym for Recovery Audit Contractor. RAC represents an attempt to review healthcare providers on behalf of Medicare and Medicaid to identify improper payments for healthcare claims for Medicare beneficiaries.