Recovery Audit Contractors

 

I. INTRODUCTION

 

Attention radiology providers and suppliers: Prepare for the audit activity has increased the insurance. The Centers for Medicare and Medicaid Services (CMS) Recovery Audit Contractor (RAC) program was made permanent, is expanding nationally, starting this year. Claim denials and overpayment determinations by the RACs are subject to the appeal process Medicare. radiology providers and suppliers are well advised to understand the appeal process and Medicare should recognize that there are many effective strategies that can be used successfully in the appeal process to defend audits; Medicare.

II. RECOVERY AUDIT CONTRACTORS

Article 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) directed the Department of Health and Human Services (HHS) to conduct a pilot program three years with CCR. The event began in 2005 in the three states with the highest expenditures for health insurance: California, Florida and New York. The purpose of the demonstration program was to determine whether the use of RAC is cost-effective to identify and correct improper payments in the Medicare FFS program. The RAC demonstration program proved highly successful financially in terms of CMS. In fact, the fiscal year (FY) 2007 alone, the RAC identified and collected 357.2 million dollars in excess, and paid only $ 14.3 million in identified insufficient to providers and health insurance providers. Based on information compiled by CMS, the RAC demonstration program only cost 22 cents for every dollar returned to the Trust Fund for health insurance.

Section 302 of the Tax Relief and Health Care Act of 2006 makes the RAC program permanent and requires expanding the program nationally later by CAR in 2010. CMS is aggressively moving forward with this expansion. During the last months of the demonstration program, CCR expanded in South Carolina and Massachusetts. According to the timetable "Expansion RAC", published on the CMS website, CMS plans to expand to 19 states by March 2008, 5 more states in October 2008, and other states by January 2009 or later. Although CMS 's has not yet extended to 19 states, as expected, radiology providers and suppliers in these countries can expect the coming into force of the RAC audit activity at any time.

Although RCCs are responsible for correcting inadequate and that the overpayment is the process of recovering the alleged overpayments that is particularly important for Medicare providers and suppliers. CCR can make decisions regarding coverage, coding and other technical issues (eg, duplicate claims). The RACs are permitted to attempt to identify improper payments resulting from one of the following:

• incorrect payments;
• Not covered services (including services which are not reasonable and necessary);
• Miscoded services (including DRG coding errors), and
• duplicate services.

When coverage of the scene or coding review of medical records requested by a Medicare provider or supplier, registered nurses (RNs) or therapists are required to make decisions regarding medical necessity and Certified coders are required to make coding decisions. RACs are not required to involve doctors in the process of reviewing medical records. However, RACs are required to employ a minimum of one FTE Contractor Medical Director (CMD), a medical doctor or doctor of osteopathy, and organize an alternate CMD if CMD is unavailable for prolonged period. CMD will provide services such as provision GUID.