DOING BUSINESS


Medicare Recovery Audit Program Both private payers and the Centers for Medicare & Medicaid Services (CMS) audit providers for suspected improper payments, many of them caused by coding errors. CMS has a robust sys- tem in place to address improper pay- ments: the Fee for Service (FFS) Recovery Audit Program. As part of the FFS audit program, recovery


regional audit administrative contractors


(RAC) review Medicare claims after payment for suspected overpayments. Medicare


contractors


(MAC), unified program integrity con- tractors (UPIC) and government agen- cies refer suspect claims to RACs. To improve the odds of favorable reimbursement and to lower the risk of an audit, keep these best practices in mind.


Stay aware of procedures with


high billing error rates that RACs are required to review. The CMS website publishes a list of approved RAC topics. Cotiviti, a RAC, also published a list of approved RAC issues as of October 2020. Respond to audit and RAC letters by


the deadline. Submit all required docu- mentation and/or overpayment by the stated deadline (30 days from the date of the letter). Know that RACs are scru- tinizing claims more closely in recent years and they have a high success rate. According to CMS data, in fiscal year 2018—most recent available data— RACs collected more than $73 million in overpayments on more than 56,000 claims. They restored about $7.6 million in underpayments on about 3,200 claims. Appeal discrepancies. While strict, RACs are not always correct. Between


2014 and 2016, the American Hospital Association found through its RAC- Trac survey that of the 45 percent of hospital


respondents that appealed


denials, 27 percent were successful. Conduct internal billing and cod-


ing audits. Internal audits ensure clean records and lower risk of audits from CMS, private payers and the IRS. Per- form billing and coding audits quar- terly and resolve any errors. Medical and technological innova-


tions advance faster than AMA’s CPT manual. By submitting accurate claims with detailed supporting documen- tation, surgeons can maintain strong revenue and avoid expensive audits.


Jessica Edmiston is the senior vice president of coding at National Medical Billing Services in St. Louis, Missouri. Write her at Jessica.Edmiston@nationalASCbilling.com.


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