Medicare to Intensify Audits in all 50 States

audit_rThe Centers for Medicare & Medicaid Services (CMS) recently confirmed that the Recovery Audit Contractors (RACs) will operate in all 50 states by the end of this year. RACs identify over payments and under payments by CMS to Medicare providers.

The RAC program evolved from the three-year RAC demonstration project stipulated by the Medicare Modernization Act (MMA) of 2003. The Tax Relief and Health Care Act (TRHCA) of 2006 made the RAC program permanent and authorized CMS to expand it to all 50 states by 2010. The permanent RAC program limits the medical record review period to three years and prohibits audits on claims paid before Oct. 1, 2007. The program requires RACs to have a physician medical director and certified coders available to discuss denials with providers.  CMS also announced the number of medical records RACs may request per National Provider Identifier (NPI) for 2009. CMS will likely adjust these limits each year.

Medical Record Limits for 2009 are:

  • 10 medical records per 45-day period for solo practitioners;
  • 20 medical records per 45-day period for 2 to 5 provider offices;
  • 30 medical records per 45-day period for groups of 6 to 15 providers; and
  • 50 medical records per 45-day period for groups of 16 or more providers.

Every group should start preparing a plan to deal with these audits. The old saying is “failure to plan, is a plan to fail”.  Groups will need to develop a system for documenting each record request and track the audit of each claim to completion. As with any audit, if your group can’t provide the documentation of the services rendered, it is as if the service was never rendered. I have provided the RAC map of the four audit companies, the states they will audit and the contact numbers for each company.

  • Diversified Collection Services 866-201-0580
  • CGI Technologies and Solutions 877-316-7222
  • Connolly Consulting, Inc. 866-360-2507
  • HealthDataInsights, Inc. 866-376-2319

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