Due to the success of the Recovery Audit Contractor (RAC) demonstration CMS currently plans to recoup a lot of monies because the permanent RAC is rolled out to any or all states by 2010.

Now is the time to organize for increased scrutiny of your Medicare claims; the RAC’s are going to be in your state soon, if they’re not already there.

The Department of Health and Human Services and workplace of Inspector General give a model compliance program to produce healthcare suppliers with steering to organize for the RAC. The seven components of a model compliance program are as follows:

  • Designation of a compliance officer and compliance committee

  • Development of compliance policies and procedures

  • Establishment of open lines of communication

  • Appropriate coaching and education

  • Internal monitoring and auditing of claims

  • Response and corrective action to detected deficiencies

  • Enforcement of disciplinary actions

  • In today’s health care setting most entities are already burdened with the each day challenge of correct billing and coding, compliant documentation, -HIPAA, physician managed care contracts, Stark laws, vendor contracts, and most significantly, patient service.

This leaves most health care entities with fewer resources to specialise in compliance and audit problems.

With that being said, how do you go concerning coping with the increased burden of potential RAC audits?

Your initial step ought to be to perform an indoor audit review of your organization’s documentation and compliance procedures. we all know that based mostly on Demonstration Project results that CMS posted that somewhere between seventieth – seventy fifth of overpayments identified were from coding errors and lack of documentation to support medical necessity. With that being said it might build sense that your organization focus your attention and resources in these areas.

For your coding accuracy and medical necessity review, it’s crucial to perform a “base line review” to guage your organizations compliance with the principles and laws. The review can assist you determine deficiencies and proper them (including issuing refunds) before the RAC auditors bringing to light. it’s conjointly crucial that you simply implement an education set up based mostly on your findings for your employees and medical suppliers. If your follow gets within the habit of performing a review, identifying errors and providing education, {you can|you’ll|you may} notice that your error rates will drop considerably.

In terms of your internal review, there are several things to contemplate. will your organization have the interior experience to determine what areas to specialise in? can you base your efforts on the RAC findings to direct your focus on cases to validate medical necessity and correct coding? There are several variables that require to be pre-determined if your organization opts to try and do an indoor RAC audits review.

You will ought to verify what number charts to review, whether or not this range may be a calculated range that’s representative of your annual billings or simply a random sample. These are simply a couple of of the queries that may ought to be answered before your organization moves forward with an inside audit review.

One issue that each facility must suppose that’s considering doing internal audits is that you just should be assured that your audits are being performed by people who are “independent”. additionally it’s essential that your audit team have the suitable talent set and credentials to be conducting the audits. For people who don’t have the resources to conduct audits internally, thought ought to be given to hiring a 3rd party audit firm that has the expertise and credentials to help your organization with the inner audit operate. When choosing a vendor, ensure you’re partaking a firm that has RAC expertise and therefore the acceptable credentials of clinical auditors to make sure that they’re going to offer you the service and talent set you wish. it’s essential that your audit results will support any findings against the RAC simply in case any audit problems arise.