Revenue Cycle

Tip: Look into the future

Recovery Auditor Report, March 5, 2009

One thing to keep in mind is that RACs cannot randomly select or target a claim “solely because it is a high-dollar claim,” according to the 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.”
According to Nancy Hirschl, president of Hirschl and Associates in Laguna Niguel, CA, that “other information” could include the following:
  • A procedure code listed in an OIG report about services that are often not medically necessary
  • A diagnosis code that a RAC believes, based on knowledge from work in the private health insurance arena, facilities may incorrectly code
  • A provider with a high utilization rate compared to other physicians or states
  • A belief that the claim payment was inconsistent with Medicare payment policy
Editor’s note: This tip was excerpted from HCPro’s Revenue Cycle Management Toolkit: A Comprehensive Guide to Managing Cash Flow.

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