Eli's Hospice Insider

Published on Mon Feb 01, 2010 PDF

Check your quiz answers here.

1. Answer: B Medicare Part A and Part B fee-for-service claims only

2. The RACs perform automated reviews that involve data-mining and also complex reviews where they request a provider's medical records. (True)

3. The RACs can request up to 200 records from a provider at a time regardless of the provider's size.

(False) For home health agencies,outpatient hospitals, and other Part A billers, RACs can review 1 percent of average monthly Medicare services (maximum of 200), explains law firm Arent Fox on its Web site. That limit applies every 45 days per National Provider Identifier number. For hospice, inpatient hospital, skilled nursing facility, or inpatient rehabilitation facility billers, RACs can review 10 percent of the average monthly paid Medicare claims (maximum of 200) per 45-day period, per NPI. For durable medical equipment, labs, and other Part B billers, RACs can review 1 percent of average monthly paid Medicare services per 45-day period, per NPI, Arent Fox says.

To reach the 200 claim maximum, therefore, HHAs would have to submit 20,000 claims per month.For hospices, they would have to submit 2,000 claims per month.

4. The RACs focus primarily on detecting fraud and abuse, and work more closely with the HHS Office of Inspector General than any other auditors.

(False) RACs are paid on a contingency basis for their recoupments, from 9 to 12 percent in current contracts. They could, however, refer potential fraud and abuse concerns on, as can MACs. RACs may do so more now that they have been criticized by the OIG for reporting almost no fraud suspicions in their demonstration project time.

5. If a claim has already been reviewed by an intermediary, carrier, or another government auditor, the RAC can still audit it.

(False) "All fee-for-service claims are subject to RAC review unless they are already being reviewed by another entity (such as an FI or MAC)," according to a presentation, "A Proactive Approach to a Recovery Audit Contractor Process," at the American Association of Homes & Services for the Aging's annual meeting in November.

"The RAC will not be allowed to review a claim that has already been or is currently under review by another entity," states the American Academy of Family Physicians on its Web site