RACs: Proven Tips and Tactics to Reduce Your Audit Risks and Appeal Payment Denials

Table of Contents

CMS Initiatives and Guidance

• CMS Switches Gears, Approves RAC Audits During Blackout Periods
• CMS: Sending Records Electronically Will Make Audits More Bearable
• CMS Nearly Doubles Investment in RACs, Has Method to Win More Provider Appeals
• New RAC Statement of Work Gives and Takes; Less Burden Promised
• Final Rule on Medicaid RACs Covers Fraud Referrals, Coordination
• In First RAC Report to Congress, CMS Says Contractor Validates RACs
• With Error Rates Remaining High, the RAC Prepayment Review Demo Returns Soon

High-Risk and Target Areas

• RAC Overpayment Identification Is Picking Up Steam; Hospitals Improve Oversight
• Scrutiny of Medical Necessity Intensifies, but Gray Areas Persist
• Kidney Injury, Urinary Surgery Are Targets as RACs Amp Up Medical-Necessity Reviews
• CMS: MS-DRGs Shouldn’t Be Coded Until MD Documentation Is Done
• Hospitals Face Scrutiny in 16 Risk Areas in OIG’s Medicare Compliance Reviews
• Top 10 Upcoming Compliance Challenges: Putting Your Money Where Your Risks Are
• RACs Audit Transfers to Post-Acute Care; Refunds to Hospitals May Be a Result
• Health System Reaches Settlement After Assigning the Wrong DRGs
• Some Compliance Programs May Fail to Reduce the Risks Of False Claims
• Medicare Auditors Target Place-of-Service Codes; Provider-Based Status Is at Risk
• MS-DRGs Targeted in RAC Prepayment Demo Raise Red Flags Despite the Delay
• Medical Necessity and Coding Challenges Make Wound Care a Ripe Audit Target
• As OIG, RAC Recoupment for Drug Units Pile Up, Predictive Modeling May Bring Relief

Facing RACs: Strategies for Success

• Greater Scrutiny, Use of PEPPER Data Will Reduce RAC Risks
• RAC Extrapolation May Not Be Too Far Off; Process Requires Hospital Oversight
• RAC Letters Are Shifted to MACs in Bid to Solve Lateness Problem
• Role of Prepayment Audits, Documentation Grow as RAC And RAC-Like Audits Multiply
• With More Audits, Health Systems May Need a Centralized Response
• RAC Audit Problems Rear Their Head Again; Some Physicians Help With Claims Denials
• Medicaid RACs Are Gearing Up, but MICs Get Bad Marks in New Report

Denials and Appeals

• RAC Medical Necessity Audits Accelerate, But Hospitals Say Some Miss the Boat
• MACs May Change Their Mind on Closed Cases, Sit on Money Too Long Post-Appeal
• CMS Opens Door to Rebilling Inpatient Denials; RACs to Start Prepayment Reviews
• After Hospital Repays MAC Millions, RAC Audits Same Claims and Recoups Again
• RACs Deny Admissions for Inpatient-Only Procedures; CMS Says There’s More to It

Written By

This book was written by the editorial staff of AIS.

Written For

Compliance officers; attorneys; and financial and operations executives at

• Hospitals
• Health systems
• Medical group practices
• Consulting firms
• Law offices

Shipping Information

Print Version: This item is shipped via UPS. Please give us your street address when you order (UPS does not deliver to PO boxes.) You should receive your order within 5-7 business days. Shipping cost is $12 per item.

PDF Version: Immediately after submitting your order through our secure shopping cart, you will receive an e-mail with a link directing you to download the PDF file of the book. If you place your order via phone, fax or mail, the PDF version will be e-mailed to you when your order is processed (usually within 1 business day). Shipping costs will not be charged for this item.

Rush orders:

Please call us at 800-521-4323 to place a rush order. We will overnight your order for an additional charge of $45, or you can give us your FedEx or UPS account number and we will charge the shipping to your account. Rush orders placed after 3:00pm EST will not be shipped out until the next business day.

View Sample (PDF)

• Read the Introduction to this Report