Bev Jenkin, HIC 

RAC (Recovery Audit Contractors) has continued to stay in the forefront of every practitioner and practice administrator's mind.  It also seems to have remainded at the forefront of the IRS' mind as well - 18,000 new agents have currently been assigned to this project.

RAC is continuing to prove itself to be not only profitable for the government, but quite a money making operation for the auditors who are able to receive payouts of 22.5% of the monies brought in through RAC audits.  Diversified Collection Auditors is the name of the New Jersey handlers group.

RAC was spawned off of the premise that it would minimize the burden on providers.  However, in 2008, during the pilot stage, RAC eased the burden to the tune of 17 billion dollars in collected refunds, and the pilot soon became the reality.

The Medicaid RAC program is due to be put into effect before 2011.

Although RAC has a look-back date of three years, meaning that is how far auditors can request charts dated from, with a show of "good cause" this period can be extended - back to the original date the practitioner enrolled in teh Medicare program.  RAC covers Medicare parts A, B, C, and D.

RAC does have specific request limits:

Solo practitioners are limited to 10 records every 45 days per group NPI number,  
Groups of 2 to 5 practitioners are limited to 20 records every 45 days,
Groups with 6 to 15 practitioners are limited to 30 records every 45 days, and
Groups with 16 or more practitioners are capped at 50 records every 45 days. 

For other Part B, the limits are:

1% of the average monthly Medicare services,
a maximum of 200 records per NPI number every 45 days.

RAC also has a specific Appeals Process.  This process is as follows:

Redetermination back to the contractor - 120 days
Reconsideration to QIC - 180 days
Administrative Law Judge - 60 days
Medicare Appeals Council - 60 days
Federal District Court - 60 days

One reason RAC is so successful is because practitioners do not challenge decisions.  Practitioners should take advantage of all RAC discussion periods.  They have forty-one (41) days from the intial overpayment demand to appeal the decision and sixty (60) days from the redetermination decision to make a timely appeal.

The ultimate responsibility for correct coding lies with teh practitioner.  The number one reason for claim denial is lack of medical necessity.  Seventy-two percent (72%) of the time, physicians code incorrectly; twenty-eight percent (28%) of the time they undercode.  Judging by those numbers, accurate coding is done, in the best scenario, twenty-eight (28%) of the time.

For the security of the practitioner, a good rule of thumb is to have an AAPC (American Academy of Procedural Coders) certified coder perform a "snapshot audit" of chart documentation and coding at least one time per year.  This type of audit should follow the "never look back" rule and focus solely on the previous day's charts - not yet filed with the insurance companies.  The AAPC certified coder should either be obtained by, or notify, the practitioner's legal representative and the practitioner's accountant of the intent of the audit and sign all necessary NDA's (non disclosure agreements) before commencing the audit.  The audit should include a comprehensive retraining of proper coding and documentation techniques.