Readers weigh in on Medicare recovery audit program

The RAC demonstration project has proven to be a huge success. Less than 5% of all claims are audited. The key to success is to ensure medical records are reviewed by qualified personnel. Most commercial insurers have managed care which provides quality and cost savings to beneficiaries. CMS has allowed providers to manage their own care which has resulted in optimization of reimbursement thru upcoding and providing services at a higher level of service than is necessary. The RAC program should be expanded to all 50 states as soon as possible to ensure solvency of the trust fund.

Based on everything that I've read about the program, it appears that CMS is more than willing to adjust the program, as needed. They added a max. look-back date, required auditors to have medical directors, coding experts, and nurses and therapists on staff, auditors must payback the fee if the claim is overturned on any level and they instituted several more revisions to refine the process.

The program is returning hundreds of millions of dollars, which were ill-gotten, back to the Medicare Trust Fund and the auditors work has been upheld approx. 95 percent of the time. All new programs have issues. So, quit crying about it, work it out and stop trying to maximize profits (i.e. bilking the gov’t and screwing taxpayers).

"The auditors work has been upheld approx. 95 percent of the time".

Statistically that '95%' number is meaningless. First of all, when they say that an audit finding has been upheld, does that mean that the payee chose not to challenge the audit, or that a second go-round between the auditors and the payees found in the auditors favor?
I would like to see a breakout by range of dollars per claim upheld or not challenged. That is, how many medical claims under, say, one or two thousand dollars were simply repaid by the payee instead of being reviewed and disputed.
Its a known fact that liability insurers routinely pay small 'nuisance' claims of several thousand dollars for such things as auto fender benders and supermarket slip and falls rather than challenge them in court, as the cost of challenging such claims would be greater than the payout.
A less-than-ethical private medicare auditor (perish the thought!) could make a tidy living demanding repayment of relatively small payments by medicare to smaller practices that do not have the resources to redo every medical claim they file. That 20% cut could add up very quickly.

Howard

howard08817@aol.com

Per the publicly posted CMS report, 95% was upheld at any level of appeal - which appears to be three levels. So, providers had three chances to win on appeal and only won 5% of the time.

Rationalize all you want and regardless of the amount, if it doesn't belong to you or it was ill-gotten... I believe that’s still considered stealing. Welcome back to pre-school, kids.

…Less than ethical. Nothing like the pot calling the kettle black... Here's a less than ethical point for you - courtesy of a 2005 GAO (public) report. So, cost of rehabilitative services for a knee or hip replacement in an inpatient rehab. facility was $17,135, compared to just $6,165 if the same services are provided in a skilled nursing facility. I bet that adds up very quickly as well and sounds less than ethical. That same report went on to conclude that billions were being bilked from the government – via Medicare – and even cited specific examples.

As a tax-payer, I do not understand what took CMS so long to audit providers. How can CMS pay a half a trillion dollars of claims without an audit program?

I have not seen what the administrative cost is for all the audits and screening all the claims.
CMS is busy auditing claims and at the same time instituting new icd 10 and 5010 standards. piecemeal in different areas of the country.

Dear taxpayer... I hope you get all the government you are paying for...

Has anyone heard if on AUTO denial you have any appeal rights and if you appeal will it stop the recoupments for happening?

I can't wait for the first RAC audit. I have seen so much of unnecessary Inpt status with poor medical necessity documentation.