More Audits and More Problems

by  Ronald Hirsch, MD FACP CHCQM CHRI
Jun 30th, 2022

More audits are coming, how do we stay compliant?

We have been saying it but now it is happening. More audits are coming your way. One of the two CMS Recovery Audit Contractors seems to have taken on a business expansion plan. It appears they are contacting payers of all types and sizes and trying to sign them up for their services. What do they do? It appears they have two business models. In their traditional one, they take old claims, already processed and paid by the payer, and audit them for “accuracy.” They then report errors to the payer for recoupment. That is what I will call the traditional model. Then they offer what some payers are calling an enhanced payment integrity model where after a payer processes claims, they send the claims to the RAC who run their algorithms and find errors the payer missed before the claim is even paid. There are of course no details on how this RAC is paid by these payers, but their model for the CMS RAC program is based on a contingency fee so that may be applicable here. And while CMS has put in place accuracy standards for the Medicare RAC program, there is no indication of what standards are in place for these audits. Could the RAC just deny liberally as we saw with the short stay CMS audits, collect their contingency fee, and hope few appeal or object to their methods? It is not outside the realm of possibilities.

Just last week a RAC Relief user reported her hospital received medical record requests for a VA claim from 2018 that was being audited and wondered if there was a rule on the lookback time frame. Sure enough, the VA has enlisted this RAC to audit claims as far back as 2017! Aside from the fact that they are going back five years, there is absolutely no payment for preparing and sending the medical records and there is no way to submit the records electronically.

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Read the entire article at RACmonitor by clicking here.

This article originally published on May 25, 2022 by RACmonitor.

About Ronald Hirsch, MD FACP CHCQM CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).