• Home
  • Practice Focus
    • Facial Plastic/Reconstructive
    • Head and Neck
    • Laryngology
    • Otology/Neurotology
    • Pediatric
    • Rhinology
    • Sleep Medicine
    • How I Do It
    • TRIO Best Practices
  • Business of Medicine
    • Health Policy
    • Legal Matters
    • Practice Management
    • Tech Talk
    • AI
  • Literature Reviews
    • Facial Plastic/Reconstructive
    • Head and Neck
    • Laryngology
    • Otology/Neurotology
    • Pediatric
    • Rhinology
    • Sleep Medicine
  • Career
    • Medical Education
    • Professional Development
    • Resident Focus
  • ENT Perspectives
    • ENT Expressions
    • Everyday Ethics
    • From TRIO
    • The Great Debate
    • Letter From the Editor
    • Rx: Wellness
    • The Voice
    • Viewpoint
  • TRIO Resources
    • Triological Society
    • The Laryngoscope
    • Laryngoscope Investigative Otolaryngology
    • TRIO Combined Sections Meetings
    • COSM
    • Related Otolaryngology Events
  • Search

Avoid the Hot Seat: How to prepare for a CMS audit

by Christopher Guadagnino, PhD • April 1, 2010

  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version

In February, the Centers for Medicare and Medicaid Services (CMS) began rolling out its national Recovery Audit Contractor (RAC) program, aimed at ferreting out improper payments and preventing fraud, waste and abuse in the Medicare system. If you bill for Medicare fee-for-service, you are fair game for a RAC audit. A three-year demonstration of the RAC program, which ended in March 2008, heavily targeted bronchoscopy, injectable drugs and IV hydration therapy. But auditors are rapidly expanding the list, and the permanent program will include adenoidectomies, tonsillectomies, thyroidectomies and other otolaryngology-related procedures.

You Might Also Like

  • Audit Agony: Prepare yourself as insurers look to recoup funds
  • Proposed Legislation Could Speed Up Audit Process, Increase Transparency
  • How to Prepare and Respond to Payer Audits
  • CMS Reimburses Sleep Apnea CPAP Treatment When Diagnosed with Home Testing
Explore This Issue
April 2010

Program Rationale and Process

CMS has contracted with four regional RACs for the permanent nationwide program; each will use proprietary auditing software to review paid claims from Medicare Part A and B providers to ensure they meet Medicare’s statutory, regulatory and policy requirements and regulations.

The RACs are ramping up their claim review activities in all states, said Connie Leonard, director of CMS’s Division of Recovery Audit Operations. When overpayments are confirmed, the RACs issue letters demanding that you repay your Medicare carrier or intermediary within 30 days. For confirmed underpayments, your carrier or intermediary forwards the additional payment to you, Leonard said.

You can repay an overpayment by check or installment plan on or before 30 days after receiving the RAC demand letter. If you haven’t made your payment by day 41, your Medicare contractor can recoup fees previously paid to you. If you wish to dispute overpayment charges, you can take your case through the usual Medicare claims appeal process. Leonard also explained that RACs offer a “discussion period,” which lasts from the date you get a “Detailed Review Results” letter until the date of recoupment, to give you the opportunity to discuss an improper payment determination outside the normal appeal process.

Some RACs are targeting adenoidectomy, tonsillectomy and several thyroidectomy codes as once-in-a-lifetime procedures.

RAC Obligations

Some physicians audited during the demonstration project found the experience onerous and abusive. In response, CMS has modified the program in several ways, Leonard said. For example:

  • RACs cannot audit claims earlier than three years from the start of the program, with a maximum look-back date of October 1, 2007;
  • RACs are limited to requesting 10 medical records per 45 days from a solo physician, 20 medical records from a small practice of two to five physicians, 30 from a group of six to 15 and 50 from a large group of more than 16 physicians;
  • Each RAC must hire a physician medical director and certified coders, and you may request the credentials of your auditor and ask to speak to your RAC’s medical director regarding a claim denial; and
  • RACs must have a Web-based claim status platform that will allow you to track the status of medical record submissions to RACs.

Codes to Watch

The majority of improper payments under the RAC demo program stemmed from providers billing for services that were incorrectly coded or did not meet Medicare’s medical necessity policies, according to the CMS.

Pages: 1 2 | Single Page

Filed Under: Departments, Health Policy, Legal Matters, Practice Management Tagged With: audit, billing and coding, healthcare reform, legal, Medicare, policyIssue: April 2010

You Might Also Like:

  • Audit Agony: Prepare yourself as insurers look to recoup funds
  • Proposed Legislation Could Speed Up Audit Process, Increase Transparency
  • How to Prepare and Respond to Payer Audits
  • CMS Reimburses Sleep Apnea CPAP Treatment When Diagnosed with Home Testing

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

The Triological SocietyENTtoday is a publication of The Triological Society.

Polls

Would you choose a concierge physician as your PCP?

View Results

Loading ... Loading ...
  • Polls Archive

Top Articles for Residents

  • Applications Open for Resident Members of ENTtoday Edit Board
  • How To Provide Helpful Feedback To Residents
  • Call for Resident Bowl Questions
  • New Standardized Otolaryngology Curriculum Launching July 1 Should Be Valuable Resource For Physicians Around The World
  • Do Training Programs Give Otolaryngology Residents the Necessary Tools to Do Productive Research?
  • Popular this Week
  • Most Popular
  • Most Recent
    • The Dramatic Rise in Tongue Tie and Lip Tie Treatment

    • Keeping Watch for Skin Cancers on the Head and Neck

    • Otolaryngologists Are Still Debating the Effectiveness of Tongue Tie Treatment

    • Rating Laryngopharyngeal Reflux Severity: How Do Two Common Instruments Compare?

    • Clinical Grading System for Reinke’s Edema

    • The Dramatic Rise in Tongue Tie and Lip Tie Treatment

    • Rating Laryngopharyngeal Reflux Severity: How Do Two Common Instruments Compare?

    • Is Middle Ear Pressure Affected by Continuous Positive Airway Pressure Use?

    • Otolaryngologists Are Still Debating the Effectiveness of Tongue Tie Treatment

    • Complications for When Physicians Change a Maiden Name

    • Excitement Around Gene Therapy for Hearing Restoration
    • “Small” Acts of Kindness
    • How To: Endoscopic Total Maxillectomy Without Facial Skin Incision
    • Science Communities Must Speak Out When Policies Threaten Health and Safety
    • Observation Most Cost-Effective in Addressing AECRS in Absence of Bacterial Infection

Follow Us

  • Contact Us
  • About Us
  • Advertise
  • The Triological Society
  • The Laryngoscope
  • Laryngoscope Investigative Otolaryngology
  • Privacy Policy
  • Terms of Use
  • Cookies

Wiley

Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 1559-4939