RAC Audits by Medicare

One of our providers had a claim that had been paid (correctly) back in June reprocessed by Medicare in September where they denied one of the services that had been previously paid. They took the money back from the provider on the same eob that they had reprocessed the claim. The denial only said “non covered charges”. I called Medicare and as soon as I gave the girl all the info so she could pull up the claim she immediately said “I have to transfer you to a Tier 2 Representative”.

Strange…..All I had asked was for an explanation of the denial. Told her I didn’t understand it.

So the Tier 2 representative comes on and pulls up the claim and says [QUOTE] “Oh, that’s an RAC audited claim, they are randomly auditing claims and reprocessing them for no apparent reason. You are going to have to request a redetermination because that denial makes absolutely no sense.”

Hmmmm…..Again, strange…………

Seriously?? I have to request a redetermination because Medicare decided to randomly audit, reprocess and deny a claim for no apparent reason and with no explainable reason??

OK…so now I could go off into a long political rant about how the government has just found another way to ‘cut costs’. I mean seriously, consider this:
• It took me a little research to even figure out what they did
• I had to dig back and find the original eob,
• figure out that the claim was reprocessed without any action on my end,
• there were multiple services on the claim so I had to sift thru to find the denied one,
• Read the denial codes to determine that it really didn’t make sense
• Make a phone call to ask
• Find the redetermination request form on their website (the correct one since I was doing an overpayment redetermination, not a regular redetermination
• Complete the redetermination request form
• Attach proof to support my claim (proof that I’m not crazy but they are!)
• Mail it
• Wait to watch for reprocessing

How many providers will never even know they had money taken away?? How many providers have staff that will go thru this trouble?? And how much did they have to pay their staff (hourly wage for time involved in taking care of this)?? More than Medicare actually took back? In some cases yes. So actually Medicare will make quite a bit of money on these RAC Audits!

I’m now stepping down off my soap box and getting back to work.

Michele Redmond
Vice President
Solutions Medical Billing Inc


2 Responses to “RAC Audits by Medicare”

  1. Claudia Says:

    Just wait until they have complete control over all of health care. Imagine all the stuff that will ‘make no sense’!

  2. solutionsmedicalbilling Says:

    Very scary thought. Makes me shudder. I know things need to be better, but I don’t believe that the current system can handle the changes they are trying to make. Most people are unaware of how things are currently handled and think that anyone who opposes the health care bill just wants things to stay the same. That’s not it. It’s just when you run into things like I described up above, it makes you wonder how they will handle the changes!?!?!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s