The Medicare Recovery Audit Contractor Program A Survival Guide for Healthcare Providers

Acronym Listing
Chapter 1 Introduction
Synopsis
Conventions Used throughout the Book
Chapter 2 Purpose, Structure, and Intent of the RAC Audit Program
Introduction
RAC Demonstration Project
Selection and Utilization of RACs
CMS and the RAC Operations
Payment of the RACs
Summary and Conclusion
Chapter 3 RAC, OIG, and Medicare Audits
Introduction
General Categories of Audits
Medicare Audits
OIG and DOJ Audits
Medicare CERT Program
OIG Guidance: Federal Register
RAC Audits
What Happened to the Underpayments?
CMS’s Approach for the RACs
Summary and Conclusion
Chapter 4 Brief Review of Healthcare Payment and Payment Systems
Introduction
Claims Adjudication Requirements
Covered Individual/Covered Services
Proper Orders with Appropriate Diagnostic Justification
Qualified Facility or Practitioner
Appropriate Documentation
Medicare Billing Privileges
Correct Claim, Filed Timely
Medicare Payment Systems
Medicare Fee Schedules
Medicare Prospective Payment Systems
Medicare Payment System Interfaces
Summary and Conclusion
Chapter 5 RAC Audit Issues
Introduction
Underlying Compliance Areas
Medical Necessity
Payment System Interfaces
Inadequate Guidance
Confusing Guidance
Sample Problem Areas by Provider Type
Hospitals
Critical Access Hospitals
Physicians and Clinics
Other Healthcare Providers
Summary and Future Issues
Chapter 6 RAC Processes
Introduction
Problem Identification, Data Mining, and Probe Audits
Automated Reviews
Complex Reviews
Extrapolation
RAT-STATS Example
Stratified Sampling
Using Extrapolation in Reverse
Summary and Conclusion
Chapter 7 Understanding the RAC Appeals Process
Introduction
Appeals Process
RAC Discussion
Request for Redetermination
Reconsideration
Administrative Law Judge
Medicare Appeals Council
Federal District Court
Pursuing the Appeals Process
Developing Organizational Resources
Case Development
Hierarchy of Medicare Guidance
Clarifying Guidance
Ambiguous Guidance
Incorrect Guidance
Requesting Guidance and the Federal Register
Coding/Billing versus Adjudication/Payment
Directives Inherent in the Payment System
Interpretation of Guidance
Other Issues
MMA 2003 Protection Provisions
Addressing Extrapolation Cases
Summary and Conclusion
Chapter 8 Meeting the RAC Audit Challenge
Introduction
Reviewing and Assessing Current CBR Compliance Program
Adapting Your CBR Compliance Program
Budgeting and Financial Impacts
Internal RAC Program Training
Summary and Conclusion

Biography

Duane C. Abbey

For many nurse leaders, understanding the mysteries of corporate compliance, the Office of the Inspector General, or the Department of Justice has been challenging to say the least. Dr. Duane Abbey has taken these topics and, specifically, the newest kid on the compliance block-the Recovery Audit Contractor (RAC) Program-and translated them into a very understandable language that nursing leaders can get their arms around, particularly in the surgical arena. … Although the subject is potentially intimidating, this book is a very engaging and understandable read for nurse leaders. As an experienced leader but one who is a novice in compliance matters, I found that the author provides this book as a tool kit to help leaders find the information necessary to proactively prepare for a RAC audit. The author does a great job of taking the technical language related to RAC audits and incorporating the use of storytelling to explain the important concepts in an understandable and engaging format. Not surprisingly, the author has more than 25 years of health care experience, with much of his time spent divided between teaching the concepts of billing and compliance and consulting with health care organizations.
—Maureen C. Chadwick, MSN, RN, NE-BC, Director, Peri-Operative Services, Saint Vincent Health Center, in the AORN Journal, May 2011, Vol. 93, No. 5