Audits and Appeals Facts: Who’s Looking?
“RACs” are private companies that conduct post-pay audits of Medicare claims. They are paid, in part, based on the amount of improperly paid funds that they recover. The RAC demonstration project, enacted as part of the Medicare Modernization Act of 2003, was conducted between 2005 and 2008 in five States. It was a resounding success, identifying over $900 Million in over payments while costing only a fraction of that amount. As a result of this success, in 2006, as part of the Tax Relief and Healthcare Act, Congress ordered the RAC program to be made permanent and expanded to all States.
Why Are They Looking?
We are seeing an increasing trend in pre-payment reviews, especially those focused on R-J modifiers (Residence to Free Standing Dialysis). Due to the subjective nature of non-emergent claims payment determinations, it is difficult for providers running these transports to win these claims on initial submission. If properly supported and argued on appeal, most of these claims should ultimately be paid. However the appeals process, and even the appeals decisions, does not stop the pre-pay review for your company.
What You Need to Know
There are as many Medicaid Appeals systems as there are States, and each one is different. Depending on the State you are in, there are unique arguments and defenses that can help you avoid overpayment assessments.
We Can Help
EMS Consultants has appealed more than $20 Million in assessed Medicare and Medicaid overpayments for our clients over the past two years. Of that amount, most of our clients have had to pay back less than 1%`, and the extrapolated amount has rarely been upheld.
Are you prepared for an audit? At EMS Consultants we have vast experience with ambulance reimbursement and know and understand the regulations and laws that are unique to ambulance services. Because of this, we are better prepared to represent ambulance suppliers.
Products and Services Offered
EMS Consultants offers professional audit and review services geared at different levels, depending upon the need the client may have. We also offer various training material, as well as lecture presentations for your seminar or meeting event.
Legal Advantage Program
The EMS Consultants Legal Advantage Program is an exclusive membership program designed to offer our clients additional value added benefits to help improve your overall compliance and improve your operations. As a legal advantage client, you will be granted access to a wide array of compliance policies and programs, contract templates and review, training programs, products and services discounts, as well as direct access to our consultants for specific questions you may have.