Claims facing more scrutiny from auditors, survey shows

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If providers feels like they're under more intense scrutiny than ever before from Medicare recovery audit contractors, there is a good reason: They are.

A recent survey shows that requests by RACs for records increased 22% from the first quarter of the year to the second quarter. Commissioned by the Centers for Medicare & Medicaid Services, RACs requested 546,000 medical records during the second quarter, according to a survey conducted by the American Hospital Association.

In March, CMS granted audit contractors the authority to request twice as many records as before in March, so there could be even more increases reflected in subsequent measuring periods.

The survey found that the increase in records requests also meant additional denials of automated and complex claims. Automated RAC denials include billing or coding errors — such as the absence of documentation in a claim. A complex denial is based on human review of medical records.

Provider groups and lawmakers have criticized RACs for being overzealous about therapy claims, leading to heightened tension between providers and regulators.

Federal regulators, however, say intensified efforts are paying off. CMS officials were reported as saying the number of defendants facing healthcare fraud charges rose significantly last year. That, in part, is a result of a quadrupling of Medicare “Strike Force” teams over the last four years, observers say. Congress has pledged $340 million toward fraud prevention over the next 10 years.

The American Health Care Association said the increased scrutiny and enforcement should be moderated. AHCA has said some auditors, such as Zone Program Integrity Contractors (ZPICs), are engaged in “stealth policymaking.”
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