The CMS initially began RAC audits in 2005 as a three year project to detect and correct improper payments in the Medicare Fee-for-Service program. The success of the program led to the Congress making it a permanent feature across the nation from 1st January, 2010. Any healthcare provider that bills Medicare under its Fee-for-Service program has to undergo RAC Audits. These audits are conducted by Recovery Audit Contractors (RACs) hired by CMS and involves reviewing, auditing and identifying improper payments received from Medicare.

An overpayment demand letter or a request for additional claim data marks the beginning of a RAC Audit. This consists of two types of reviews:

  1. Automated reviews that use data mining to identify payment errors, and
  2. Complex reviews where medical records are closely examined to ensure that the treatment given by the provider was medically necessary for the patient.

These audits are subject to definite timelines and can become a challenge for healthcare providers who do not have a systematic approach to the manner in which medical records and documents are stored.  Healthcare providers have 45 days to provide the medical records to the RAC auditors under complex reviews.  Providers get 120 days to file an appeal for re-determination of the review. There are essentially four levels to the providers appeal:

  1. Redetermination to Medicare Contractor
  2. Reconsideration to a Qualified Independent Contractor
  3. Hearing before an Administrative Law Judge
  4. Review by Medicare

RAC Audit challenges faced by healthcare providers:

  • Complex documentation to meet RAC audit requirements
  • Cumbersome process where data entry is done manually
  • Time and cost for managing the process
  • Departmental fragmentation hinders efficient management of compliance and audits
  • Appeals are generally a complex procedure and time consuming
  • Readiness for a RAC Audit by preparing for one

Why MedConverge
MedConverge proactive approach involves automation, streamlining and integrating the preparation for RAC Audits. We offer advanced capabilities featuring integrated document management, built-in system for status tracking and reporting, remediation action workflows – thus providing all aspects of RAC audit requirements on a common centralized platform and helping our clients deal with RAC audits in both a proactive and reactive manner. MedConverge offers the following solutions for your RAC audit requirements :

  • Internal audit management
  • Compliance management
  • Document management
  • Issue management
  • Training management

MedConverge solutions are custom built, depending on the client’s requirements. However, the following key features are part of every solution that we offer:

  • Automated workflows
  • Scalable and extendable
  • With embedded best practices and matching industry standards
  • Dashboards that allow enhanced monitoring and reporting
  • Issue remediation alerts and notification
  • Centralized management
  • Fast implementation
rac audits