Wiki Medicare Take Back Due To RAC

[MichelleAKing]

Our office received an EOB from Medicare stating that they were taking back money on a claim due to a RAC audit. They said that the documentation did not support the level of service. We have never been asked to submit any records for a RAC audit. This doesn't seem right to us and we are wondering if there is anyone out there that may have experienced this. We are under the impression that when a RAC audit is done, you are notified and asked to submit records. In this situation, it almost seems as if the audited off of the HCFA form. I would appreciate hearing back any thoughts on this.
Thank you.

 

[RebeccaWoodward*]

That is a little surprising; at least to me. I was also under the same impression that medical records would be requested 1st. Below is, supposedly, an recently updated FAQ on RAC.

Will the Recovery Audit Contractors (RAC) review evaluation and management (E&M) services on physician claims under Part B?Published 07/19/2006 01:56 PM | Updated 05/18/2010 05:29 PM |

Yes, the review of all evaluation and management (E & M) services will be allowed under the RAC program. The review of duplicate claims or E & M services that should be included in a global surgery were available for review during the RAC demonstration and will continue to be available for review. The review of the level of the visit of some E & M services was not included in the RAC demonstration. CMS will work closely with the American Medical Association and the physician community prior to any reviews being completed regarding the level of the visit and will provide notice to the physician community before the RACs are allowed to begin reviews of evaluation and management (E & M) services and the level of the visit.

 

[Lisa Bledsoe]

I found this on CMS:
Under what circumstances can, a Recovery Audit Contractor (RAC), make a finding that an overpayment or underpayment exists without requesting medical records?
RACs may use automated review (where NO medical record is involved in the review) ONLY in situations where there is certainty that the claim contains an overpayment. Automated review must:
a) have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment);
b) be based on a medically unbelievable service; or
c) occur when no timely response is received in response to a medical record request letter.

 

[josephmglick]

I'd verify what company is contracted to do the RAC audits for your area and visit their webiste or contact them and see how they are handling their audits. The one in my area sends letters and it has all of their own company logos on it, not CMS. We missed a few that went to our medical records dept in the big pile they already have for records request and had money taken back for failure to submit records. So all of our staff have been given a sample letter & envelope showing what it looks like and what logos to watch for and it goes directly to billing for a quick audit and quick response.