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Auditing for RACs, MACs and OIG:
Preparing Tribal Health Programs



In 2012, there will be an unprecedented number of Medicare and Medicaid audits that health care providers are likely to endure. The Patient Protection and Affordable Care Act (also know as the health reform law), enacted March 23, 2010, mandates the expansion of Recovery Audit Contractor (RAC) audits beyond Medicare to Medicaid by the end of 2010. RACs are paid a percentage of the over and underpayments they find in high-cost categories of service and will needle out errors that have nothing to do with actual patient care. The Centers for Medicare & Medicaid Services (CMS) has been working on implementations with the AMA in preparation for RACs to cast over into medical practices by 2011.

Now is the time to learn what these government contractors are after (an illegible signature may be enough for denial!) and how to guard against potential losses. If overpayments are discovered, providers must return the money immediately.

Clinical documentation is the driving force to support medical necessity, which in turn drives the denial of a claim. CMS and the OIG are currently focusing on clinical documentation and medical necessity to find reasons to deny claims in audits. Additionally, Medicare PSC, ZPICs, the Medicare One PI system and Medicaid Integrity Contractor (MIC) and Medicare Administrative Contractors (MACs) audits are all ongoing CMS audits and initiatives focused on provider payment that can affect tribal health programs.

This class will help you to ensure that your organization is prepared for audits from each of these organizations, and it will help you to understand the root causes for payment denials and fix issues at the source. Don't wait until you receive payment denials to find the weaknesses in your tribal health program - register for this information packed course today.

T O P I C S   I N C L U D E
Important Protective Measures
  • Creation of mechanisms for effective communication between billing and clinical staff
  • Providing expeditious documentation
  • Submission of claims with all proper documentation for auditing purposes
  • Legible organization of medical notes used for claim submission
  • Prohibiting any financial incentive for billing codes
  • Periodic internal or external audits
  • Constant monitoring of claims
  • Record requests tracking systems
  • RAC appeal timelines and levels
Audits
  • RACs
  • MACs
  • MICs
  • Medicare PSC
  • ZPICs
  • The Medicare One PI system
  • The OIG
  • E/M auditing
  • Compliance
  • Diagnosis auditing
  • Hands-on auditing
  • Auditing from the physician's point of view
  • "Look back" periods
  • Reserve estimates
Most Recent Areas of Focus for Denials
  • Documentation problems
  • Medical necessity
  • Illegible signatures
  • Poor organization of claims documentation
  • Duplicate claims
  • Categories of services with highest overpayment rates
Conducting a Baseline Audit

Creating a Formal Record Request Handling Policy

The OIG Work Plan 2011

HIPAA "Safety Nets"
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