Pre-Audit Risk Assessment/RAC Preparedness Evaluation

 

Utilizing a fully Automated Claims Evaluator (ACE) system, detection occurs at the optimum time—as the claim is coded and before it is released for payment.  This allows for accurate coding, promoting quality data while reducing the need for costly post-discharge reviews and corrections. ACE allows coders to reduce billing delays; and real-time reporting capabilities deliver insight on coding effectiveness.

 

The Pre-Audit Risk Assessment/RAC Preparedness Evaluation:

  • Identifies compliance issues before claims are submitted by reviewing records before they are presented for payment
  • Improves cash flow by identifying fraud, waste, abuse and errors during claims processing
  • Improves reliability and accuracy of claims data, while facilitating coding audits and compliance reporting
  • Provides global reporting mechanism to review, monitor and audit all claims transactional data
  • Enables tracking and trending of Recovery Audit Contractor (RAC) issues, enhancing the RAC team’s workflow

Get RAC ready results so you're not the next victim...

RAC Resource                                                                                       

The Medicare Modernization Act of 2003 established the Medicare Recovery Audit Contractor (RAC) program as a demonstration program to identify improper Medicare payments - both overpayments and underpayments. RACs were paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers.

 

Under the demonstration program that operated from March 2005-March 2008 in California, Florida and New York, South Carolina and Massachusetts, RACs could review the last four years of provider claims for the following types of services: hospital inpatient and outpatient, skilled nursing facility, physician, ambulance and laboratory, as well as durable medical equipment. The RACs used proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries' mistakes, medical necessity and coding. RACs also conducted medical record reviews. In July 2008, CMS reported that the RACs had succeeded in correcting more than $1.03 billion in Medicare improper payments. Approximately 96 percent ($992.7 million) of the improper payments were overpayments collected from providers, while the remaining 4 percent ($37.8 million) were underpayments repaid to providers.

The Tax Relief and Healthcare Act of 2006 made the RAC program permanent and authorized the Centers for Medicare & Medicaid Services (CMS) to expand the program to all 50 states by 2010. Nationwide rollout of the permanent RAC program is underway, with all states scheduled to come on board this year.

Are you RAC ready?

The HRS "best of breed" RAC Assurance Program has provided management, organizational and auditing services to Managed Care Organizations (MCOs), Health Maintenance Organizations (HMOs) and government organizations of all sizes to address the growing need to curb fraud, waste and abuse in healthcare, and more importantly making our clients RAC Ready.

The unique background of our "best of breed" RAC Assurance Program has provided the insight to address the needs, wants and requirements of any healthcare organization reducing the fraud, waste and abuse prevalent in today's healthcare industry.

Our "best of breed" RAC Assurance Program is based on a dynamic forensic claims integrity system and the expertise of 30+ years of insurance consulting. This allows clients to mitigate their risk in upcoming RAC audits while the program's unique insight enables them to accurately respond and appeal during the audit process.

 

Our "best of breed" RAC Assurance Program breaks down the audit process by:

  • Logging and tracking record requests and managing all processes.
  • Improving communication among RAC team members.
  • Tracking, storing and reporting types of issues for re-opening claims, take back amounts, and overall outcomes.
  • Proactively identifying potential RAC issues and areas of risk.
  • Offering real-time reporting capabilities with over 100+ reports.
  • Aggregating RAC data to provide on-demand submission to the American Hospital Association's RACTrac Survey.
  • Offering expert legal and healthcare consultation.

 

Our clients are provided with a complete claims integrity solution to ensure that the claims processed are not only correct but fall within regulatory guidelines. Leveraging this expertise, the company has created a comprehensive hospital solution to ensure claims integrity not only retrospectively but on an ongoing basis as well. We audit the claims history in order to provide either a pre-RAC audit baseline to understand payment behaviors, effects and areas of risk. On an ongoing basis as new claims are created, these files will be scrubbed by our systems, ensuring on-going claims integrity.
 

Our "best of breed" RAC Assurance Program

The foundation of "best of breed" RAC Assurance Program is based on a dynamic forensic claims integrity system that has over 30+ years of insurance consulting experience. Pairing an in-depth technological and expert review of client data, clients can mitigate risk in upcoming RAC audits by resolving problem areas before RAC is involved.

 

The "best of breed" RAC Assurance Program breaks down the audit process by:

  • Pro-actively Identifying Potential RAC Issues and Areas of Risk
  • Logging and Tracking Record Requests and Managing All Processes
  • Offering Real -Time Reporting Capabilities with over 100+ Reports
  • Tracking, Storing and Reporting Types of Issues for Re-Opening Claims, Take-Back Amounts, and Overall Outcomes
  • Aggregating RAC Data to Provide On-Demand Submission to the American Hospital Association’s RACTrac Survey
  • Improving Communication among RAC Team Members
  • Offering Expert Legal and Healthcare Consultation

 

Overview of Services

The claims integrity solution ensures that processed claims are not only correct but comply with regulatory guidelines. We will audit the claims history before the pre-RAC (Recovery Audit Contractor) audit to create a baseline of data behaviors and identify areas of risk. On an on-going basis as new claims are created, these files will be scrubbed by the our systems, ensuring on-going claims integrity.

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