Medicare Compliance & Reimbursement

Tip: ADR timelines may differ by audit type.

Now that Medicare claims reviews are back in full swing, you should prepare for heightened scrutiny. Whether you are re-training staff or need a refresher course on the various claims auditors or audit types yourself, it’s a good idea to start with the fundamentals.

Gauge your understanding of the different Medicare claims auditors and kinds of reviews with 10 tough questions and answers on the basics.

1. Which claims auditor determines the improper payment rate for the Medicare fee-for-service (FFS) program?

A. Recovery Audit Contractor

B. Zone Program Integrity Contractor

C. CERT Statistical Contractor

D. Medicare Administrative Contractor

2. What type of audit targets at-risk Medicare providers, utilizing three rounds of reviews with 20 to 40 claims reviewed per round?

A. Targeted Probe and Educate review

B. RAC audit

C. SMRC review

D. MIC audit

3. How many years can RAC auditors look back from the date your claim was paid?

A. 1 year

B. 3 years

C. 6 years

D. 10 years

4. What audit type uses data analysis in choosing which providers to investigate?

A. Unified Program Integrity Contractor

B. Recovery Audit Contractor

C. Medicare Administrative Contractor

D. None of the above

5. There are _______________ types of RAC audits.

A. 2

B. 3

C. 4

D. 5

6. How many days do you have to respond to requests for additional documentation in a TPE review?

A. 30

B. 45

C. 60

D. 120

7. What kind of audit could be initiated after an employee issues a complaint?

A. MAC review

B. RAC Audit

C. SMRC review

D. ZPIC audit

8. Which MAC currently runs the Supplemental Medical Review Contractor (SMRC) program?

A. CGS Medicare

B. Novitas Solutions

C. Noridian Healthcare Solutions

D. Palmetto GBA