Government Audits and RACs Flashcards
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Read the first 7 Government Audits and RACs flashcards as text
Which entity administers the Recovery Audit Contractor (RAC) program on behalf of CMS?
Answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the RAC program and contracts with private auditors to identify improper Medicare and Medicaid payments.
What is the maximum look-back period that a RAC can use when reviewing Medicare fee-for-service claims?
Answer: 3 years
RACs are generally limited to a 3-year look-back period from the date the claim was paid.
A RAC identifies a claim as a potential overpayment but has not yet issued a demand letter. What is this stage called?
Answer: Discussion period
The discussion period allows providers to submit additional documentation or discuss findings with the RAC before a formal demand is issued.
Which type of RAC review requires human review of medical records before an improper payment determination is made?
Answer: Complex review
Complex reviews involve a clinical review of medical records and are used when automated data analysis alone cannot confirm improper payment.
When a RAC issues an overpayment demand letter, within how many days must a provider file a redetermination request with the MAC to begin the appeals process?
Answer: 180 days
Providers have 120 days from receipt of the initial determination (demand letter) to file a redetermination request at Level 1 of the Medicare appeals process.
In the context of RAC audits, what does 'underpayment' mean?
Answer: An instance where Medicare paid less than it should have under the rules
RACs can identify both overpayments and underpayments; an underpayment occurs when Medicare paid less than the correct amount under applicable rules.
Which government program specifically targets Medicaid fraud, waste, and abuse through state-level audits, separate from the federal RAC program?
Answer: Medicaid RAC (MIC) program
The Medicaid RAC (formerly MIC) program requires states to contract with auditors to identify Medicaid improper payments, analogous to the Medicare RAC program.