Hospitals and Health Systems Subject to RAC Audits
The Recovery Audit Contractor ("RAC") program will be operating nationwide by 2010. The Centers for Medicare and Medicaid Services ("CMS") believes that the RACs in the nationwide permanent RAC program will initially focus review activities on hospitals and health systems. During the RAC demonstration program, 85 percent of all claim denials made by RACs involved inpatient hospital claims.
Although the areas that will be subject to review during the permanent RAC program cannot be predicted with certainty, reviewing the categories of claims denied during the RAC demonstration program (which are published as part of the RAC Demonstration Evaluation Report), and reviewing other CMS guidance (e.g., the annual OIG Work Plan document) can assist hospitals and health systems to determine potential areas of RAC scrutiny.
During the RAC demonstration program, many claim denials involved inpatient hospital services that were alleged to be medically unnecessary, and many other claim denials involved inpatient hospital services provided in the "wrong setting" (i.e., CMS believed the services could have been provided in a lesser care facility or as hospital outpatient services).
Wachler & Associates, P.C., has proven experience in the RAC audit and Medicare appeals process. During the RAC demonstration program, our firm successfully represented hospitals and health systems subject to RAC audits and claim denials. Additionally, attorneys at our firm are frequently asked to write and speak to professional and provider organizations regarding RAC audits and Medicare appeals. For example, our attorneys have been asked to write and speak to the organizations listed below, among others:
Publications
"Audit Impact: Expanded Liability for Overpayments," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq.,The RAC Monitor, July 2011.
"Weathering a Medicare Audit: Overview of the Medicare Appeals Process," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., MGIS Talking Points Newsletter, Vol.2 No. 3, June 23, 2011.
"Contractor Involvement in the Medicare Appeals Process," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, June 13, 2011.
"One Year Later The Impact of Health Care Reform on Health Care Provider Audits and Compliance Programs," Andrew B. Wachler, Esq., Jennifer Colagiovanni, Esq., and Christopher J. Laney, Esq., Michigan Bar Journal, June 2011.
"RAC Medical Necessity Denials of Inpatient Services - Fair & Equitable Reimbursement," Andrew B. Wachler, Esq., The RAC Monitor, April 21, 2011.
"The Use of Payment Suspensions in the Audit Landscape," Amy K. Fehn, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, March 24, 2011.
"Prepare for Increased RAC Activity in 2011," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., Wachler & Associates, The RAC Monitor, December 7, 2010.
Speaking Engagements
"Strategic Approaches to Challenging Inpatient-Outpatient Denials at the ALJ Hearing," RAC Monitor Webinar, June 28, 2011.
"RACs, ZPICs, and More - The Latest Improper Payment Initiatives for Governing Audits," MGMA Webinar regarding Recent Proper Payment Initiatives, May 12, 2011.
"Preparing for and Surviving a Third Party Payor Audit," Indiana Medical Society in Merrillville, IN, April 27, 2011.
"The New Landscape of Audits: MICs, MACs, RACs and ZPICs" co-presented with Susan Emanuel, System RAC Coordinator, Catholic Healthcare West, Phoenix, AZ; and Dawn Crump Network Director of Compliance, SSM Health Care St. Louis, Orlando, FL, HCCA's 15th Annual Compliance Institute, April 13, 2011.
"Medicaid RAC Appeals - Similarities and Differences with Medicare RAC Requirements and Processes," 5th Annual Medicare RAC Summit, Washington, D.C., March 9-11, 2011.
"Medicare and Medicaid Audits: A Year in Review," American Health Lawyers Association (AHLA) Hospital and Health Systems Law Institute, Las Vegas, NV, February 11, 2011.
Please click here for a more complete listing of our attorneys' publications and speaking engagements.
The Importance of Compliance
Although hospitals and health systems cannot stop RAC audits from happening, they can immediately put systems in place for:
- Tracking record requests and timely responding;
- Implementing appropriate compliance programs (which would include monitoring your hospital's admission and utilization review procedures); and
- Making efforts to understand the Medicare appeals process and available audit defenses.
Contact Us
Call us at 877-403-6048 or send us an e-mail to schedule a meeting to discuss your concerns with RACs or to discuss your other healthcare law-related needs.
