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Biggest RACs Changes Are Here: Learn to Avoid Denied Claims

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Three changes to the RAC program could threaten your organization. There are new rules for using extrapolation; new changes to additional documentation requests (ADR); and there is a new audit for inpatient total knee arthroplasty (TKA).

Price: $229.00

Product Code: AR021919


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This webcast will review the biggest changes to Recovery Audit Contractor (RAC) audits in 2019. The RACs returned $214 million to the Medicare program in fiscal year 2016, according to the latest annual report released by the Centers for Medicare & Medicaid Services (CMS).

First, CMS revised the rules for extrapolation, effective January 2, 2019. CMS also modified when extrapolation can and shall be used. Now if the error rate is more than 50 percent, the RAC auditor shall extrapolate.

Second, this update changes the additional documentation requests (ADR) "cycle" limit, from zero (0) to one (1), for those providers who, under the previous methodology, would have an ADR "cycle" limit of zero (0), even though their "annual" ADR limit was greater than zero (1, 2, 3, 4).

A baseline annual ADR limit is established for each provider based on the number of Medicare claims paid in a previous 12-month period that are associated with the provider's 6-digit CMS Certification Number (CCN) and the provider's National Provider Identifier (NPI) number. Using the baseline annual ADR limit, an ADR cycle limit is also established. After three (3) 45-day ADR cycles, CMS will calculate (or recalculate) a provider's Denial Rate, which will then be used to identify a provider's corresponding "Adjusted" ADR Limit. RACs may choose to either conduct reviews of a provider based on their Adjusted ADR Limit (with a shorter lookback period) or their baseline annual ADR limit (with a longer look-back period).

Third, CMS placed a two-year ban for Medicare contractors to review inpatient total knee arthroplasty (TKA) procedures because hospitals were performing knee replacements in the less expensive outpatient setting. That two-year lift will come to an end.

Why This is Relevant:

If you are a provider who accepts Medicare and Medicaid patients, you are subject to audits by the RACs. That means that you need to know the rules that a RAC auditor must follow otherwise you will not know whether the RAC auditor is abiding by the rules or exerting more power over your facility than the RAC legally has.

Learning Objectives

From this crucially important webcast, you and your team will benefit from the following:

  • Understand the new RAC rules;
  • Learn how to defend your organization against extrapolation;
  • Know about the new additional documentation request (ADR) limits;
  • Learn about total knee replacement audits; and
  • Gain insight into the future of RAC audits on provider types

Who Should Attend:

Chief financial officers, case managers, inpatient coding and HIM professionals, hospital compliance and audit and appeal managers and directors, RAC coordinators, financial specialists, analysts, revenue cycle personnel, and clinical documentation improvement specialists.