The RACs are paid on a percentage, or contingency, basis for finding improper payments. Thus, in theory, the incentive to find underpayments is the same as for finding overpayments. However, as we will explore, the whole Medicare RAC program has been constructed and organized to find overpayments, not underpayments: that fact is certainly obvious gauging by the 3.67 percent figure from the CMS report.

Healthcare consulting firms for years have worked to assist every type of provider to identify circumstances in which payments under a variety of payment systems can be increased. Sometimes the word optimize is used, but the OIG has frowned upon using this or maximize because it suggests that consultants, particularly on a contingency basis, are incentivized to find underpayments where none actually may exist.

Interestingly enough, it appears that RACs can be incentivized on a contingency basis to find overpayments that actually may not exist. At the very least, overpayments may be claimed by the RACs on a subjective basis, such as by questioning medical necessity.


Types of Audits

There are many different types of audits; chapter 15 of “Compliance for Coding, Billing & Reimbursement[1] discusses a number of these.  Among them are:

  • Probe Audits
  • Pre-Payment Audits
  • Base-Line Audits
  • Stratified Audits
  • Chargemaster Audits
  • E/M Coding Audits

The list can go on. Some audits depend on a given perspective. A third-party payer may conduct pre-payment audits to ensure that inappropriate payments are not occurring. Some audits are specialized; for instance, a hospital may have a chargemaster audit to ensure that the chargemaster is compliant and charges are correct. For healthcare providers audits can be classified as:

§        Prospective Audits

§        Concurrent Audits

§        Retrospective Audits.

Prospective audits
address the systematic process of providing services, documenting services, and coding and billing for services. The emphasis is on the processes and associated sub-processes utilized throughout the reimbursement cycle.[2]

Concurrent audits
look at the systematic processes in addition to samplings of current claims. Generally, current claims are in the 90- to 180-day range and may or may not be paid. The purpose of such audits is to identify weaknesses in the processes by analyzing current end products – namely the claims. If possible, reimbursement also is audited. A real advantage with current claims is that they can be corrected and refiled if errors or omissions are identified.

Retrospective audits
look back in time and consider only paid claims.  Often the claims considered are so old that there is no opportunity to correct and refile them, but if there is an overpayment found, then a repayment is appropriate, and on rare occasions underpayments may be identified. In general, though, these underpayments are lost.

Auditors of all types have been using these types of audits for many years.  For instance, the OIG or DOJ may decide to investigate a particular issue -in some cases, they have gone back as far as seven years in conducting retrospective audits. Consultants assisting healthcare providers in reimbursement enhancement generally use the prospective and concurrent audits, but also routinely conduct retrospective audits looking for possible errors.

One of the dilemmas created by prospective and concurrent audits is that they can uncover a systematic error. The error may be generating underpayments or overpayments. If overpayments are occurring and have occurred in the past, what should the healthcare provider do? The simple answer is to perform a retrospective audit to verify possible overpayments and the extent to which they may have occurred.


Optimizing Reimbursement

Consultants assisting a healthcare provider such as a hospital or clinic generally will look at the overall system flow from patient encounter all the way through claim payment. There are many sub-processes and associated questions. Consultants will look for patient services or items dispensed that never made it onto a claim. Missed charges and documentation deficiencies are always suspect. Perhaps additional training of physicians can assist in developing better diagnostic statements, which in turn assists in better coding, which itself results in increased payments.

The process of optimizing reimbursement typically involves either prospective audits or concurrent audits. It is examination of the systematic processes of providing services and the associated documentation, coding, billing and reimbursement that can yield significant improvements. These are the two types of general auditing approaches that consultants have used for years to assist healthcare providers.

Now, healthcare providers certainly have used retrospective audits on a routine basis as well. For instance, hospitals typically have retrospective audits for inpatient services (e.g. Medicare DRGs) and outpatient services (e.g. Medicare APCs). Physicians and clinics typically have annual audits of proper E/M level coding. If these retrospective audits detect any sorts of problems, which would be mainly overpayments, further investigations can be conducted. Typically these types of annual audits find sporadic overpayments and, less frequently, underpayments.

However, if you really want to find circumstances in which underpayments or even non-payments are occurring, the overall reimbursement cycle must be examined, analyzed and improved as appropriate.


CMS’s Approach for the RACs

RACs use data mining to identify possible problem areas. Automated reviews are retrospective reviews of paid claims. The automated reviews look for real and potential aberrations in coding and billing by various healthcare providers.

The complex reviews also actually do look at the supporting documentation, however, the main intent of them is to scrutinize on a retrospective basis, looking for specific issues such as medical necessity for hospital admissions. Typically, the intent of a complex review is to verify that the documentation justifies the provisions of service and corresponds with the coding and associated claim that was filed. The RACs also look for weaknesses in the documentation relative to identified or potential overpayment problems.

Have you ever heard of a RAC checking documentation because of possible under-coding issues?

The RACs can and will use other types of audits. For instance, the RACs can request a limited number of records, usually 10, in order to determine if a suspected problem area really is a problem.[3] This is a type of probe audit; however, do not confuse this type of small audit with probe audits that are conducted as part of an extrapolation process. These probe audits will be for 30 or more cases, depending upon the size of the universe being considered.

The RACs are allowed to review current claims, but it is unlikely that this would include unpaid claims. Current claims in this case generally point to the fact that you could refile the claims if the RAC found and substantiated an overpayment. Note that the time period for re-filing claims is a rather convoluted algorithm found at 42 CFR §424, that is, the Conditions for Payment (CfP) section of the Code of Federal Regulations.

Bottom Line
: If you have any hope that the RACs will find significant amounts of underpayments, know that this most likely will never occur. The RAC auditing processes are geared to address paid claims, and generally on a retrospective audit basis. While some underpayments may be found, they generally are identified through either prospective audits and/or concurrent audits. Again, these are the types of audits that consultants have used for years to assist healthcare providers in receiving proper payments.


About the Author

Duane C. Abbey, Ph.D., CFP, is an educator, author and management consultant working in the healthcare field. He is president of Abbey & Abbey Consultants, Inc., which specializes in healthcare consulting and related areas. His firm is based in Ames, Iowa. Dr. Abbey earned his graduate degrees at the University of Notre Dame and Iowa State University.

[1] See author’s “Compliance for Coding, Billing & Reimbursement: A Systematic Approach to Developing a Comprehensive Program“, 2nd Edition, CRC Press, ISBN=978-1-56327-368-1.

[2] We could use the phrase ‘revenue cycle’, but we are focusing on generating claims for which reimbursement is made.

[3] These small probe audits are not included in the medical record limitation for complex reviews.

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