Highlights from the Prepare for an Audit Form
Recovery Audit Contractors (RACs) detect and correct past improper payments so that CMS and Carriers, and Medicare Administrative Contractors (MACs) can implement actions that will prevent future improper payments. Initially, RAC took aim at large-scale facilities, such as hospitals and nursing homes, but now CMS is turning a RAC spotlight specifically on the post-acute care providers-home care, hospice and DME. The next round of RAC contractors will include a RAC to focus specifically on these providers. These audits are likely to be widespread and will target common mistakes.
Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other health care professionals, and submit payment to those providers in accordance with Medicare rules and regulations. This includes identifying and correcting underpayments and over payments. If the MAC verifies an error exists through a review of a sample of claims, it classifies the severity of the problem as minor, moderate or significant and imposes corrective actions appropriate for the severity of the infraction.
Zone Program Integrity Contractors (ZPICs) identify cases of suspected fraud and take appropriate corrective actions such as CMS administrative action or referral to law enforcement. ZPICs perform medical reviews; data analysis; identify the need for administrative actions such as payment suspensions and prepayment or auto denial edits. ZPICs may require medical records and documentation; conduct an interview; and/or perform an onsite visit.
Comprehensive Error Rate Testing (CERTs) contractors work with the MAC to lower error rates. The CERT review contractor selects random samples of claims from each Medicare claims processing contractor for medical review. The CERT program was developed by CMS to oversee Medicare fee for service payments.
Meaningful Use Audits CMS and the Office of Inspector General (OIG) have taken steps to audit how providers are meeting meaningful use requirements. Approximately 5 to 10 percent of all meaningful use participants are being audited; however, this number may rise.
To access the Prepare for an Audit Form:
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- Along the left hand side of the page you will see several gray tabs.
- Now click on the Forms tab and search for Prepare for an Audit.
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