Tuesday, July 20, 2021

What is a RAC audit in Medicare?

The word audit strikes fear into the calmest of hearts. It can come from the IRS, your employer, or if you run a Hospice or home healthcare business, you may have an audit from the Centers for Medicare & Medicaid Services that is performed by a Recovery Audit Contractor. Any home health care provider who bills fee-for-service programs is subject to such an audit.

As a home health care agency, you have a couple of options for keeping yourself compliant. You can either hire an accountant who specializes in Medicare, or you can use software designed for Medicare compliance.

Why Do They Audit a Business?

The CMS has increased audits of home health care agencies in recent years. The purpose of the Medicare Fee for Service (FFS) Recovery Audit Program is to find illegitimate Medicare payments. An auditor will do this by looking at discrepancies in payments made to Medicare providers or patients. They generally look for over-payments.

The company that does the audit must employ certain people in the medical field so they can properly evaluate the cost of certain medical services. An auditing company will employ therapists, coders, as well as doctors and nurses.

Recovery auditors only review payments that have already been made. They can go back as far as three years from the date of any questionable payments.

How are auditors chosen?

There are only three companies that are authorized to provide audits for Medicare Fee for Service (FFS) Recovery Audit Programs. Each company provides service to a certain region. Illinois is considered Region 2, and services are provided by Cotiviti, LLC.

Who audits the auditors?

Auditors are human too, so they make their fair share of mistakes. All the decisions they make will be reviewed by the CMS. All auditing companies are reviewed once a year for the accuracy of their reports. Auditors charge a contingency fee for each audit that they perform. If an auditing company should end up losing an appeal, they must return the fee.

What Happens When They Find Something Wrong

An auditor may review automatic, semi-automatic, and more complex payments. They should give the home healthcare company the opportunity to discuss any inappropriate payments that they find. If the auditor detects any impropriety, they will request that you send in payment. The healthcare provider for hospice can pay by check, or they can make a payment plan. They can also allow money to be deducted from future payments.

What if the auditor makes an error?

According to Rosenblat Law, if you feel that the auditor has made an error, you can appeal their decision. There are five different levels of appeal, and it is important to hire a defense attorney who specializes in these kinds of audits to represent you.

A professional attorney will know how to negotiate with the CMS and what questions to ask auditors. They will be familiar with the auditing protocol, and any common mistakes auditors make.

 It is best to find an attorney who has worked as a prosecutor on Medicare fraud cases. They will know what kinds of challenges to expect and what arguments will work to win your case.

Getting audited is frightening, but it is not always guaranteed that an auditor will find any wrongdoing. It is always a good idea to keep very accurate records and use a software program or an accountant that you can trust for your billing needs.

If you do need to appeal an auditor's decision, a good attorney can help you avoid paying fees and avoid further audits.

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This is a guest blog entry.

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