Use caution when reviewing data before RAC audit
Use caution when reviewing data before RAC audit
Good intentions can backfire when it comes to preparing for RAC audits, cautions Rebekah Plowman, JD, an attorney specializing in health care litigation with the law firm of Epstein Becker in Atlanta. Risk managers may think they can save their organizations the expense and hassle of a high error rate by analyzing their records before the RAC auditors and self-disclosing, but Plowman says that can be tricky.
CMS now has the ability to audit all the way back to 2007, so any claims submitted as far back as 2007 are open for review, Plowman says. That creates a lot of potential for errors.
"There's really not much you can do about those claims unless you want to take a close look at them and go back and resubmit them," she says. "If you thought your billing and coding people really had a problem and didn't understand how to code a particular service or procedure, you could take them out of the system and resubmit them. That would help you avoid getting a really significant error rate when the audit occurs."
The error rate discovered by the auditors is significant not only because of the potential money involved but because a high error rate can trigger a criminal investigation. Plowman says her contacts at the Department of Justice (DOJ) tell her that any error rate over 50% will be investigated. Error rates between 20% and 50% will be sent to the DOJ for evaluation, but not all will be formally investigated.
Another way to minimize the impact is to conduct a close review of all your claims and self-disclose any errors. However, that would have to be done under the advice of counsel, Plowman cautions.
"The 50% error rate seems high, like you would never expect to reach that threshold without an intentional effort to commit fraud, but it can happen. When you have problems with coding a particular procedure, an honest mistake that accumulates over time, you can have that much of an error rate," she says. "If it goes to the DOJ, it is being evaluated as a false claim. Then you're in that nightmare."
Plowman points out that overzealous introspection can produce its own problems. If you mine your own data to identify problem payments in an effort to reduce the impact of the RAC audit, you must be ready to deal with the results.
"If you identify an overpayment and don't turn it over to the government, it is a false claim. The new amendments to the False Claims Act make that very, very clear," she says. "So, if you mine your data, find problems, and then you decide you don't really have the money to send back to the government or someone higher up than you says no to the proposition of volunteering a refund, then you have a false claim. So, you don't necessarily want to go back and audit everything in the past."
Good intentions can backfire when it comes to preparing for RAC audits, cautions Rebekah Plowman, JD, an attorney specializing in health care litigation with the law firm of Epstein Becker in Atlanta.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.