Peggy Says from Med Trade in Orlando

Peggy Says  from Medtrade in Orlando

Oct  2013

RAC Audits    DANGER –DANGER- THREATS – THREATS

The big bad wolf of competitive bidding is really awful! But the “little” Red Riding Hood called the RAC auditor makes the big bad wolf look like a cocker spaniel puppy —-

RAC audits occur basically because of statistics – numbers pulled and reviewed and they see an unusual pattern ie:  an increase in billing of a specific code or group of codes / high increase in billing for a code the supplier has never billed before/ change in billing codes from a specific code that has been on a pre-pay to another code that is not being looked at closely.

The auditor will then begin auditing and requesting documentation.

If A RAC auditor request documentation on a CLAIM that you have already been audited on by another contractor for the very same claim the RAC should stop their process once you have informed the RAC that this has happened. They are not supposed to review a claim or group of claim (s) that has already went through the audit by one contractor and paid.

If you receive these immediately open a conversation with the RAC and explain what has happened and send them a copy of the audit results you have already received. This should stop the audit process.

Make sure you open this discussion immediately and hold off sending for a Redetermination until your time limit is close or the RAC rescinds their decision. Make sure you keep track of timing so you do not pass your timely file for a redetermination.

The RACs are not supposed to audit you on a claim that has already been audited by another entity.

If you go to redetermination make sure you send EVERYTHING you have with the first review & checks to make sure you do not have other errors as well.  Address any other errors you may find. Use check off sheets from your DMEMAC or the examples of clean claims you will find on the VGM web site.  

When a RAC auditor successfully recoups money from a provider they do get a percentage of that recoupment BUT if this is over turned at a later date thru the appeals process the RAC is to be offset from further payments that they would have received.

If you continue to have these issues you need to notify myself or [email protected]  of the issue(s) so we can help you. Remember that VGM is here to help you SURVIVE in the ever changing world of audits and any other issues our industry is facing.

Any assistance or questions please call me or Ronda Buhrmester:

Peggy Walker, RN  US Rehab/VGM  800-491-3643

Ronda Buhrmester, RT US Rehab/VGM  888 665 6518