Preparing for Medicare's hired guns

Published: 2011-03-15 17:17:19
Author: Jennifer Kirschenbaum and Rachel Weinrib | ChiroEco | March 2011

If you haven’t heard, Medicare is utilizing third parties, otherwise known as Recovery Audit Contractors (RACs), to identify services provided by doctors who do not meet the many documentation requirements now required by Medicare for reimbursement.

For example: There have been patient’s visits denied based on lack of qualitative measures of patient improvement in plans of care or failure to identify a medical reason for a visit, both convictions leading to a determination of failure to provide medical necessity for care.

Conveniently, RACs are reimbursed a percentage of the reimbursement recouped from the services they identify as unsubstantiated for Medicare reimbursement, and therefore, determinations of unsubstantiated care are rampant.

By all accounts, the RAC review process is not a fair process. Given a big enough haystack, you are bound to find some needles. Records are requested and thereafter, dissected and recalibrated in ways that rattle the best of documenters.

Of late, the results presented by clients indicate the RACs are looking to establish that the majority of chiropractic medically necessary visits submitted for reimbursement are in fact maintenance visits and therefore not reimbursable by Medicare.

You may be thinking that if you are not the target of this type of audit as of yet, there is still time to take “preventative measures.” While this is true, the RAC is authorized to look back at your records for three years.

Any intentional alterations to medical records after the fact may be construed as fraudulent behavior. Keep in mind that this reference is not meant to stop you from amending a record appropriately, which would include adding a new entry signed and dated contemporaneously in an old visit.

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