RAC Vulnerabilities Highlighted in CMS Release

CMS just released its first in a series of articles that will disseminate information on Recovery Audit Contractor (RAC) high-dollar improper payment vulnerabilities. The objective of such articles is to provide education regarding RAC demonstration-identified vulnerabilities to prevent the same problems from happening in the future.

CMS notes two high-risk vulnerabilities identified during the RAC demonstration: provider non-compliance with timely submission of requested medical documentation and insufficient documentation that did not justify that the services billed were covered, medically necessary, or correctly coded.

According to CMS, due to the implementation of the permanent RAC program and the initiation of complex medical review, including coding and medical necessity, it is now more important than ever for providers to understand and implement the lessons learned from the RAC demonstration. CMS is therefore encouraging all providers who submit fee-for-service claims to Medicare fiscal intermediaries (FIs) or Part A/B Medicare administrative contractors (A/B MACs) are urged to review the article and take steps, if necessary, to meet Medicare’s documentation requirements to avoid unnecessary denial of claims.

For more information on this topic, feel free to call Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. of The Health Law Partners at (248) 996-8510.