How do I become a RAC auditor?

What triggers RAC audits?

RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare’s clinical payment criteria, documentation and billing requirements.

What does RAC stand for audit?

What does a Recovery Audit Contractor (RAC) do? RAC’s review claims on a post-payment basis. The RAC’s detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.

How many Medicare Recovery Audit Contractor regions are there in the United States?

CMS awarded contracts to four regional RACs (regions noted by A, B, C and D in the map).

Who performs RAC audits?

There are currently three firms that administer RAC audits, according to CMS’ website: Performant Recovery Inc., Cotiviti LLC and HMS Federal Solutions, and the company that comes calling depends on your agency’s geographic region.

How are RACs paid for their services?

RACs are paid on a contingency fee basis, which means they are reimbursed based on a percentage of the improper payments they find or collect. The amount of the contingency fee is based on the amount of money from, or reimbursed to, providers.

When did RAC audits start?

2005

In 2005, CMS implemented the Medicare Recovery Audit Contractor (RAC) Program as a demonstration program for Medicare fee-for-service (FFS); Medicare Parts A and Part B. The pilot program successfully corrected more than $1.03 Billion in Medicare improper payments.

What is an RAC in college?

Purpose: To ensure that resources are distributed in accordance with the new Integrated Planning Model framework.

What are CMS audits?

These program audits measure a sponsoring organization’s compliance with the terms of its contract with CMS, in particular, the requirements associated with access to medical services, drugs, and other enrollee protections required by Medicare.

How many years back can CMS audit?

3-year

Recovery Auditors who choose to review a provider using their 0.5% baseline annual ADR limit may review under a 3-year look-back period, per CMS approval.

Why do CMS and RAC auditors have the right to access your medical records?

RAC auditors will usually request medical records to complete the audit. For example, they may request medical records that detail a more complex procedure to ensure you were paid correctly for the services you provided.

What is a 935 overpayment?

• Section 935(f)(2)(a) of the Medicare Modernization Act of 2003. (MMA) required CMS to change the way Medicare recoups. certain Provider, Physician, or other Supplier overpayments. and requires the payment of interest when the Provider, Physician or other Supplier prevails at the ALJ or subsequent.

What is a 935 appeal?

Limitation on recoupment (935) process



Accruement continues until debt is fully satisfied. Fully satisfied means paid in full or overturned by appeal.

What is the difference between a redetermination and an reopening?

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What is a redetermination?

A redetermination is a periodic review of your eligibility to make sure that you are still eligible for a subsidy and if so, to determine whether you should continue to receive a full or partial subsidy.

What is FFS Medicare?

Fee-for-service is a system of health care payment in which a provider is paid separately for each particular service rendered. Original Medicare is an example of fee-for-service coverage, and there are Medicare Advantage plans that also operate on a fee-for-service basis.

What are the 4 types of Medicare?

There are four parts of Medicare: Part A, Part B, Part C, and Part D.

• Part A provides inpatient/hospital coverage.
• Part B provides outpatient/medical coverage.
• Part C offers an alternate way to receive your Medicare benefits (see below for more information).
• Part D provides prescription drug coverage.

Which program pays for physician services?

Medicare

The amount Medicare pays physician service providers (such as physicians, podiatrists, and nurse practitioners, referred to collectively as “physicians”) can vary based on where the service is provided (such as a SNF, hospital, or physician’s office).

Is FFS the same as PPO?

Fee-for-Service (FFS) Plans with a Preferred Provider Organization (PPO) An FFS option that allows you to see medical providers who reduce their charges to the plan; you pay less money out-of-pocket when you use a PPO provider. When you visit a PPO you usually won’t have to file claims or paperwork.

Is FFS covered by insurance?

While some transgender people may have access to Gender Reassignment Surgery (GRS), an overwhelming majority cannot afford Facial Feminization Surgery (FFS). The former may be covered as a ‘medical necessity’, but FFS is considered ‘cosmetic’ and excluded from insurance coverage.

Why is PPO more expensive?

The additional coverage and flexibility you get from a PPO means that PPO plans will generally cost more than HMO plans. When we think about health plan costs, we usually think about monthly premiums – HMO premiums will typically be lower than PPO premiums. Another cost to consider is a deductible.

What is FFS vs HMO?

An FFS plan usually contracts with a preferred provider organization (PPO) for network discounts. You may choose any doctor or hospital, but may have lower out-of-pocket expenses with PPO providers. An HMO plan provides care through a network of physicians, hospitals and other providers in a particular geographic area.

How do PPOs save consumers money?

How do PPOs save consumers money? B. The organizers and the providers agree upon medical service charges that are generally less than the providers would charge patients not associated with the PPO.

What are the two main types of health insurance?

There are two main types of health insurance: private and public, or government. There are also a few other, more specific types. The following sections will look at each of these in more detail.