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RAC audits are here; prepare with these reminders from the ISMA
e-Reports, June 1, 2010
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The ISMA has learned that Indiana’s Recovery Audit Contractor, CGI Technologies, has started to audit hospital and physician Medicare claims. So, here are some important reminders to assure your RAC audit readiness.

“Take time to review available information about RAC audits and start looking for an N432 remark code on all your Remittance Advice, which indicates a claim is being adjusted due to a RAC review,” said Jeri Biedenkopf, R.N., ISMA practice advisor. “Also remember you can visit the physician portal to check on the status of any audit.”

Find the portal here; click on “Providers” in red at the top.

There are two types of audits, automated that do not require medical records and complex that do. Both are done on a post-payment basis as a way to detect and correct past improper payments, as well as prevent future ones.

Both automated and complex audits are underway now, and you may not know auditors are looking at your claims in an automated audit until you get a letter requesting a payback.

Caps and campuses
The Centers for Medicare & Medicaid Services has now implemented caps on the amount of medical records that can be requested in any 45-day period, based on the prior year’s Medicare claims volume. The cap is determined on a “per campus” basis annually. A campus is defined as one or more separate facilities or practices in a single organizational umbrella unit.

The medical records limitation or cap will be based on:

  • Your Tax Identification Number (TIN)
  • First three positions of the Zip code(s) where your facilities are physically located

Here are two examples to further clarify:

Practice A’s TIN is 123456789 and it has offices in two locations, Zip codes 12345 and 12346. The two locations qualify as a single campus unit for purposes of the cap on additional documentation because the first three positions of the Zip codes are the same.

Practice B’s TIN is 123456780 and the practice has offices in Zip codes 78901 and 89012. This practice is considered as two distinct entities for additional documentation purposes because the first three positions of the Zip codes are different.

See these previous ISMA Reports articles on RAC audits for more information:

Also see the CMS website or send an e-mail to CMS.

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