The Medicare Recovery Audit Contractor Program,9781439821015

The Medicare Recovery Audit Contractor Program

by
ISBN13: 9781439821015
ISBN10: 1439821011
Format: Nonspecific Binding
Pub. Date: 2017-11-15
Publisher(s): Taylor & Francis
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Table of Contents

Acronym Listing
Introduction
Synopsis
Conventions Used throughout the Book
Purpose, Structure, and Intent of the RAC Audit Program
Introduction
RAC Demonstration Project
Selection and Utilization of RACs
CMS and the RAC Operations
Payment of the RACs
Summary and Conclusion
RAC, OIG, and Medicare Audits
Introduction
General Categories of Audits
Medicare Audits
OIG and DOJ Audits
Medicare CERT Program
OIG Guidance: Federal Register
RAC Audits
What Happened to the Underpayments?
CMS's Approach for the RACs
Summary and Conclusion
Brief Review of Healthcare Payment and Payment Systems
Introduction
Claims Adjudication Requirements
Covered Individual/Covered Services
Proper Orders with Appropriate Diagnostic Justification
Qualified Facility or Practitioner
Appropriate Documentation
Medicare Billing Privileges
Correct Claim, Filed Timely
Medicare Payment Systems
Medicare Fee Schedules
Medicare Prospective Payment Systems
Medicare Payment System Interfaces
Summary and Conclusion
RAC Audit Issues
Introduction
Underlying Compliance Areas
Medical Necessity
Payment System Interfaces
Inadequate Guidance
Confusing Guidance
Sample Problem Areas by Provider Type
Hospitals
Critical Access Hospitals
Physicians and Clinics
Other Healthcare Providers
Summary and Future Issues
RAC Processes
Introduction
Problem Identification, Data Mining, and Probe Audits
Automated Reviews
Complex Reviews
Extrapolation
RAT-STATS Example
Stratified Sampling
Using Extrapolation in Reverse
Summary and Conclusion
Understanding the RAC Appeals Process
Introduction
Appeals Process
RAC Discussion
Request for Redetermination
Reconsideration
Administrative Law Judge
Medicare Appeals Council
Federal District Court
Pursuing the Appeals Process
Developing Organizational Resources
Case Development
Hierarchy of Medicare Guidance
Clarifying Guidance
Ambiguous Guidance
Incorrect Guidance
Requesting Guidance and the Federal Register
Coding/Billing versus Adjudication/Payment
Directives Inherent in the Payment System
Interpretation of Guidance
Other Issues
MMA 2003 Protection Provisions
Addressing Extrapolation Cases
Summary and Conclusion
Meeting the RAC Audit Challenge
Introduction
Reviewing and Assessing Current CBR Compliance Program
Adapting Your CBR Compliance Program
Budgeting and Financial Impacts
Internal RAC Program Training
Summary and Conclusion
Table of Contents provided by Publisher. All Rights Reserved.

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