Revenue Cycle

What RACs are looking for

Recovery Auditor Report, September 4, 2008

An important tip to keep in mind is that RACs cannot randomly select claims or target one “solely because it is a high-dollar claim,” according to the draft Statement of Work. A RAC can only “target a claim because it is a high-dollar claim and contains other information that leads the RAC to believe it is likely to contain an overpayment.”

Nancy Hirschl, BS, CCS, president of Hirschl and Associates in Laguna Niguel, CA, and a RAC Report advisory board member, specifies that the “other information” could include the following:

  • Diagnosis codes that may be incorrectly coded based on RAC experience in the private health insurance arena
  • Diagnoses that often present physician documentation insufficiencies
  • Procedure codes that do not correlate with diagnosis codes
  • Procedure codes that may indicate inappropriate site of service/inpatient status
  • Incongruent charge to payment comparison
  • The belief that the claim payment was not consistent with Medicare payment policy

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