What you need to know about Recovery Audit Contractors

By Dava Stewart

For most people, regardless of which accounts are being inspected or who the official is, the idea of an audit is anxiety inducing—and when your very livelihood is in question, it’s even more nerve-wracking. Doctors of chiropractic in the United States are liable to be audited through the Recovery Audit Program, which is run by the Centers for Medicare and Medicaid (CMS).

According the CMS website:

“The Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.”

The program is administered through Recovery Audit Contractors (RACs). There are four auditors, and each is responsible for “identifying overpayments and underpayments” in approximately one quarter of the country. The auditors look at claims submitted by all types of care providers, including DCs. The RACs are paid based on the number of improper payments they identify, so they are motivated to investigate as many claims as possible.

What does this mean for you? It means that, regardless of whether you are participating or non-participating, your claims to Medicare or Medicaid are likely to be audited. However, it is important to note that there are two types of RAC reviews:

There are two types of RAC reviews:

• Automated. An automated review is exactly what it sounds like, and providers are not required to submit additional documentation.
• Complex. In the case of a complex review, the RAC will request additional documentation.

It is always a good idea to practice risk mitigation. In addition to keeping accurate and up-to-date records, there are a few other steps you can take to protect your practice.

Here are a few resources to help you feel less trepidation at the idea of an audit:

• The CMS created a pamphlet that explains “The Who, What, When, Where, How and Why?” of RACs. It provides a broad overview of what RACs do and what providers can expect, as well as a list of things providers can do to be ready in the case of a review. You can find the pamphlet here.
• The American Chiropractic Association (ACA) created a list of useful facts about the recovery program; you can see that list here.
• The ACA has also provided information you will need should you receive an RAC audit. There are tips on how to respond, how to prepare your documents for submission, and much more. Find the article here.

The best risk mitigation, of course, is to make sure your records are accurate. Many DCs have found that the right electronic health records (EHR) system can help, but much depends on the quality of the software and the support of the vendor. Make sure your staff has sufficient training, as well, so they too understand where, why, and by whom your practice could be audited.