Recovery Audit Contractor Program Essay examples

1194 WordsOct 27, 20125 Pages
Recovery Audit Program (RAC) Christina W. Furbert Devry University HIT230 Health Insurance and Reimbursement Professor Ingram Table of Contents What is RAC?..............................................................................................................................................................3 What type of audits will the RAC program cover?.....................................................................................................3 What could happen if it is discovered by RAC that health care organization may be committing fraud? Is there an appeal…show more content…
The goal of the RAC program is to identify improper payments made for claims for health care services of Medicare beneficiaries, identify and prevent fraud, abuse and waste of Medicare payments paid to health care providers under fee-for-service Medicare plans.(Georgia Medicaid RAC) In order to identify these issues RAC does a review process (audit) to detect these underlying issues. What type of audits will the RAC program cover? The two types of review processes that the RAC program utilizes are the automated review and the complex review. The automated review requires no medical record; errors found during the automated review must be clearly noncovered services or incorrect application of coding rules and must be supported by Medicare policy, or approved by coding guidance.(Georgia Physician) The complex review requires a medical record, and may require a physician to submit medical documentation. In addition, records requiring a complex review are those with high probability of noncovered service or when on definitive Medicare policy, Medicare article, or Medicare sanctioned coding guideline exists.(Georgia Physician) RAC audits can review all aspects of the medical record including but not limited evaluation and management (E/M) services as related to those that should be reimbursed as a component of a global surgery package, as well as those on duplicate claims. By CMS regulations RACs are generally permitted to
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