Healthcare - Medical Claim Audits

Managing RAC and other Medical Claims Audits

Medicare RAC, Medicaid RAC, MIC, and other medical claims audits embody significant risk to legitimate revenues and profit margins for healthcare providers. These audits typically include very complex appeals processes with stiff penalties such as the automatic recoupment of funds if appeals deadlines are missed, even by as little as one day.

To further complicate matters, the introduction of the Medicaid RAC program as mandated by the Healthcare Reform legislation adds a new level of complexity certain to jeopardize the legitimate revenues of healthcare providers. State Medicaid agencies are permitted to use their current appeals process, modify their existing process, or devise an entirely new process for Medicaid RAC audits.

The importance of using a flexible claims audit software system capable of handling all medical audit types has never been more pronounced. Healthcare providers need a solution that can help them take control of the entire audit process, including their initial response to record requests, determining if and when to appeal denied claims, and ensuring timely replies throughout the appeals process.

After working with hundreds of hospitals managing RAC and other medical claims audits, we’ve encountered challenges and requirements that are very consistent from one organization to the next. From this, we’ve identified the requirements that we believe are critical to achieving success with any Claims Audit solution. Click here to read what we've learned.

The Compliance 360 Claims Auditor™ helps healthcare providers manage a wide variety of medical claims audits and appeals, including Medicare RAC, MIC, Medicaid RAC, MAC, ZPIC, CERT, PERM, MFCU, Commercial Payor Audits, and others. The Claims Auditor is part of the industry leading Compliance 360 solution for healthcare that enables a comprehensive approach to regulatory compliance and risk management through one comprehensive, enterprise-wide platform.

With the Compliance 360 Claims Auditor for CMS Medicare RAC Audits, you can:

• Take control of the audit process to minimize the risk of losing your legitimate revenues.

• Automate the management of the entire audit process across all departments and create organizational accountability with highly configurable workflow. With automated workflow and specific workflow templates for Automated and Complex RAC audits, the Claims Auditor functions as your “Virtual Audit Coordinator”, enforcing deadlines and due dates throughout your organization and providing alerts that enable your team to avoid the automatic recoupment of legitimate revenues.

• Integrate Medicare RAC and other audits into your “Claims Audit System of Record”. Use the Compliance 360 Claims Auditor as your central location for managing Medicare RAC audits and all medical claims audits including MIC, Medicaid RAC, MAC, ZPIC, CERT, PERM, MFCU, Commercial Payor Audits, and others. With the Compliance 360 Claims Auditor, there is NO ADDITIONAL COST, as you expand the use to incorporate all claims audits. There is no need to purchase or install additional software. The expansion is accomplished using configurable workflow capabilities and audit-specific workflow templates provided by Compliance 360.

• Make well-informed decisions throughout complex RAC audit and appeals processes and proceed with appeals only when the outcome is likely to be successful.

• Provide executive visibility with real-time dashboards. Executives and other key decision makers can closely monitor the status of pending audit appeals and any other claims audit appeals to gauge the financial exposure of active medical claims audits.

• Proactively establish barriers to Auditors by demonstrating an “in control” status with efficient self assessments and internal defense audits.

• Incorporate medical claims audit management into your broader compliance and risk management programs using the comprehensive Compliance 360 GRC platform. This is important for hospitals and healthcare systems seeking to address the increasing governance and risk management needs of their boards of directors and investors in today’s climate of increasing regulatory scrutiny and demands for oversight.

• Accomplish all of these objectives without installing or maintaining any software or additional computers. The entire Compliance 360 system including the Claims Auditor is provided as a secure Internet service that can be accessed from any location.

• Utilize complementary advisory consulting services to assess vulnerabilities and implement process improvements based on CMS guidelines. These services can also be used to assist with the defense of audits and preparation for appeals.

Demonstrations of the Compliance 360 Claims Auditor for CMS Medicare RAC Audits

To learn more about using the Compliance 360 Claims Auditor to manage your RAC audits and appeals we invite you to view a recorded demonstration of the system:

• Compliance 360 Claims Auditor: Take Control of RAC Audits
  On-demand web demo
• Compliance 360 Claims Auditor: Take Control of MIC Audits
  On-demand web demo

Free RAC Audit Training (Live and On-Demand Webinars)

You are also invited to attend our live broadcasts or replay our on-demand recorded training webinars at your convenience. These training webinars have been attended by more than 10,000 participants and have received very positive feedback.  Click Here for the full list of live and on-demand training webinars.

Learn More

To learn how leading healthcare providers are using Compliance 360 to minimize their compliance overhead and risks, and how you can be doing the same, contact us today.