The Medicare Recovery Audit Contractor Program
A Survival Guide for Healthcare Providers
Medicare fraud is big business, but while only a few profit from intentional malfeasance, the Centers for Medicare & Medicaid Services is now taking a closer look at everyone. The Medicare Recovery Audit Contractor Program, already infamously known as the RAC, swings into full operation in 2010 and every healthcare provider that receives payment under any of the Medicare fee-for-service payment systems will be subject to RAC scrutiny. And scrutinize, they will… .
Instead of developing another bureaucracy, the government has turned the job of auditing over to outside firms whose payment will be based exclusively on finder fees for recouping improper payments. There will be little tolerance for poor record keeping or gray areas of coding.
Written by medical billing guru and Lean accounting expert, Duane Abbey, The Medicare Recovery Audit Contractor Program: A Survival Guide for Healthcare Providers explains all that is required to prepare and successfully defend against inappropriate RAC audit recoveries. Using the same succinct style that always makes his writing so accessible, Abbey illustrates his lessons with simple case studies placed in the context of a fictitious community whose population is served by a hospital, clinics, a nursing facility, and other providers all seeking to maintain compliance and profitability.
In discussing RAC guidelines, this resource —
- Shows how to identify overpayment areas and associated compliance issues
- Details a systematic problem-solving process relative to RAC processes
- Addresses resource requirements including new personnel, such as RAC specialists
- Includes planning models for developing compliance departments
- Provides an extensive glossary to make sense of medical billing’s alphabet soup of acronyms
While the book works well as a stand-alone reference for those seeking advice on RAC audits, readers will also discover that this volume extends the lesson of Abbey’s classic Compliance for Coding, Billing & Reimbursement, Second Edition , making this book a natural companion for those wanting to fully explore the role of compliance and Lean accounting in medical billing.
Table of Contents
Acronym Listing. Introduction. Purpose, Structure, and Intent of the RAC Audit Program. RAC, OIG, and Medicare Audits. Brief Review of Healthcare Payment and Payment Systems. RAC Audit Issues. RAC Processes. Understanding the RAC Appeals Process. Meeting the RAC Audit Challenge.
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