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Claims Audit Management
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Medicare RAC Audit Management
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EHR Integration

Sample Customers

  • Cancer Treatment Centers of America
  • Caris Healthcare
  • Cincinnati Children's Hospital Medical Center
  • Evanston Northwestern Healthcare
  • Fairview Health Services
  • Jackson Health System
  • Legacy Health System
  • Lourdes Hospital
  • Maricopa Integrated Health System
  • Methodist Hospital
  • Multicare Health System
  • Nash Health Care Systems
  • Nassau University Medical Center
  • The Nebraska Medical Center
  • OU Medical Center
  • Palomar Pomerado Health
  • PeaceHealth
  • Sacred Heart Health System
  • St. Francis Hospital
  • Spartanburg Regional Healthcare System
  • Spectrum Health System
  • St. Luke’s Health System

Healthcare - Medicaid RAC Audits

The Affordable Care Act of 2010 required States and territories to establish Medicaid Recovery Audit Contractor (RAC) programs. The Medicaid RAC program is expected to operate in a manner similar to that of the existing Medicare RAC program, i.e., audit contractors are paid on a contingency basis to identify and recover Medicaid overpayments, as well as, underpayments.

On September 14th, 2011, the Centers for Medicare & Medicaid Services(CMS) announced the final rule for the Medicaid RAC Program scheduled to take effect on January 1st, 2012. The Medicaid RAC program is not expected to replace the existing MIC program and CMS has stated that while they hope to minimize the likelihood of overlapping audits, they still may be necessary. As if dealing with overlapping audits weren't enough, the rule also calls for states to either utilize an existing appeals process, presumably from their current MIC programs, or adopt an entirely new appeals process.  Regardless of which appeals process is selected, it is most likely to differ from the existing Medicare RAC appeals process and differ from state to state.

So what is a healthcare provider to do?  One option that is already proving successful with concurrent Medicare RAC and MIC audits is to take control with a single robust software application capable of handling the complexity and volume of many different claims audit types each with different time frames, deliverables, and appeals processes.  

Using Compliance 360 to Manage Medicaid RAC Audits

The Compliance 360 Claims Audit Manager helps healthcare providers manage a wide variety of medical claims audits and appeals, including Medicaid RAC audits. Claims Audit Manager 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 Audit Manager for Managing Medicaid RAC Audits, you can:

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

  • Automate the management of the entire Medicaid RAC audit process across all departments and create organizational accountability with highly configurable workflow.  With automated workflow, the Claims Audit Manager functions as your “Virtual Medicaid RAC 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.

  • If your organization operates in multiple states, you will need a solution with the flexibility to manage appeals processes that will vary from state to state.  Using the configurable workflow in the Compliance 360 Claims Audit Manager, you can establish unique workflows based on the audit and appeals process in each state while you centralize the management and monitoring of each audit.

  • Integrate Medicaid RAC audits into your “Claims Audit System of Record”. Use the Compliance 360 Claims Audit Manager as your central location for managing Medicaid RAC audits and all medical claims audits including Medicare RAC, MAC, MIC, CERT, PERM, MFCU, ZPIC and others.  With the Compliance 360 Claims Audit Manager, 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 Medicaid 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 Medicaid RAC audit appeals and any other claims audit appeals to gauge the financial exposure of active medical claims audits.

  • Proactively establish barriers to Medicaid RAC Auditors by demonstrating an "in control" status with efficient self-assessments and internal defense audits.

  • Incorporate Medicaid RAC audit management into your broader compliance and risk management programs using the comprehensive Compliance 360 GRC platform. This is important for hospitals and managed care organizations seeking to address the increasing governance and risk management needs of their boards of directors 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 Claims Audit Manager 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 MIC audits and preparation for appeals.

With Compliance 360, you can manage the entire Medicaid RAC audit process, from the initial receipt of a request for records, through your State appeals process and adjudication. You can also establish efficient projects for managing proactive self-audits. Using random samples from your claims history, based on the high risk targets of the Medicaid RAC Auditors, you can quickly assess your financial and legal risks. Armed with this information, you can make informed decisions regarding self-disclosure which often results in favorable treatment such as reduced or eliminated interest and penalties in many states. As an example of the potential favorable treatment for self-disclosure, see the State of New York OMIG Self-Disclosure Guidance.

Learn More

To learn how other healthcare organizations are using Compliance 360's Claims Audit Manager, we invite you to download the following case studies:

If you'd like to request a personal demonstration of the Compliance 360 Claims Auditor, please Contact Us.

Free Medicaid RAC Audit Training (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.

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