Healthcare and Medical Insurance

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Healthcare and Medical Insurance

Our Healthcare practice serves two sets of clients: Government and Private Sector. We support the work of healthcare practitioners to get them audit ready and ensure that their claim submissions are in compliance with Medicare and Medicaid Guidelines.

In 2005, Congress authorized the Recovery Audit Contractor (RAC) program to do a demonstration in California, New York, Florida and three other states. The purpose – to discover areas of fraud and waste and recover overpayments made by Medicare due to improper coding and compliance with Medicare guidelines. The result – over $900 million in overpayments recovered and returned to the Medicare Trust Fund.

Section 302 of the Tax Relief and Health Care Act of 2006 made the Recovery Audit Program permanent. Congress authorized the RAC program to be rolled out to all 50 states and Puerto Rico no later than January 1, 2010.

The Medicare audit of all beneficiaries of Medicare payments (i.e. – those who file claims with Medicare) is here to stay. If your practice is out of compliance, it could end up costing you thousands of dollars.

Anyone who files claims with Medicare is all affected. This includes the following: Physicians, hospitals, home health agencies and durable medical equipment providers. If you fall into one of the above categories, expect a notice soon from the contractor in charge of the audit in your region. They will not tell you what they are looking for. That is left up to you.

The RACs are compensated on a contingency basis based on the amount of overpayments that they find. They are going to be aggressive. Overpayments will have to be returned and Medicare isn’t going to send you an invoice and wait for the money. They will just take a portion of your current and future claims payments until the overpayment is paid in full. In extreme cases, Medicare may suspend a practices claims privileges all together. Protect yourself by following a few easy procedures:

  • Conduct an internal assessment of submitted claims to make sure they follow Medicare guidelines. You, your staff, or a third-party auditor can do this. However, a qualified third-party auditor may be the best option as this allows for someone outside your practice to give you a second opinion. If you choose to do it yourself, look for claims that have been denied in the past and review the RAC’s website.
  • Let a certified coder review a sample of your files and help you identify any pattern of inconsistent or improper coding. Again, a third-party audit service is an excellent option. A qualified auditor should have certified coders on staff, preferably with government auditing experience as well.
  • Comply with Medicare’s request for medical records in a timely manner. Failure to do so may cost you the right to appeal any decisions by the RAC that you disagree with.
  • Implement corrective actions to ensure compliance with Medicare guidelines prior to the RAC visit to your office. The sooner you do this, the less money you will cost yourself when the RAC finally gets around to you. If you choose to use a third-party auditor to assist you, they should provide you with a report on areas for improvement as well as consult with you on other areas of compliance as well.

Healthcare Financial Management Consulting Service

You can rely on us for the following services: Physicians, hospitals, home health agencies and durable medical equipment providers:

  • Internal Assessment of Submitted Claims
  • Compliance Reviews of Selected Files
  • Develop and Implement A Corrective Action Plan to Meet Medicare Guidelines
  • Audit Liaison for Recovery Audit Contractors

You don’t have to fear the RAC with the right preparation and implementation of processes. Some good may come out of your audit. During the same demonstration in California, New York, Florida and three other states, $38 million in underpayments to providers was made. You may find areas where you have been underpaid, so it isn’t all bad news.

Government and Recovery Audit Contractors Practice

We partner or subcontract with Recovery Audit Contractors and conduct audit work for direct state health agencies and the U.S. Department of Health and Social Services. We provide the following services:

  • APC Validation Audits
  • DRG Validation Audits
  • RUG Validation Audits
  • Inappropriate Admission Review (IAR)
  • Medical Chart/Hospital Bill Audits
  • Recovery Audit Sub-Contracting

Our experts include certified public accountants, fraud examiners, certified medical coders, nurses and therapists. Call us on 703-594-4944 for one hour free consultation.