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Avoid the Hot Seat: How to prepare for a CMS audit

by Christopher Guadagnino, PhD •

Of particular concern to otolaryngologists under the permanent RAC program are once-in-a-lifetime procedures (codes that can be performed only once per patient lifetime), said Charles F. Koopmann, Jr., MD, MHSA, immediate past coordinator of practice affairs of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS).

Some RACs are targeting adenoidectomy, tonsillectomy and several thyroidectomy codes as once-in-a-lifetime procedures. These codes represent the biggest risk, Dr. Koopmann said, because otolaryngologists don’t always remove all of the tissue, and it is not uncommon for tissue to grow back. “You don’t take out all the adenoids in the usual patient. There’s often residual lymph tissue. In some patients you may do a very limited adenoidectomy to reduce hypernasal speech,” said Dr. Koopmann, who is also associate chair of otolaryngology at the University of Michigan Health System in Ann Arbor, Mich.

Manage an RAC Audit

You can minimize practice disruption from a RAC audit by taking pre-emptive action, Dr. Koopmann said. His advice:

  • Read the RAC material on CMS’s Web site (www.cms.hhs.gov/RAC) to identify current and future audit targets;
  • Educate your staff now about the RAC program. Make certain they know what your RAC’s letterhead and envelope look like. You only have 30 days to respond to a RAC letter, so you don’t want it to lie somewhere unopened;
  • Designate a point person who will act as a liaison with your regional RAC. Train a backup person as well; and
  • Learn the Medicare appeals process. If you think you’re correct, be firm and appeal as quickly as you can. If not, pay as soon as you can.

Robin L. Wagner, COPM, executive director of the Association of Otolaryngology Administrators, also suggested the following:

  • Log all RAC requests onto a spreadsheet;
  • Provide all medical records within 45 days of the RAC’s request;
  • If you receive a notice of overpayment, you can either submit a rebuttal to your RAC auditor or file an appeal directly with your fiscal intermediary (FI). The time allowed for a rebuttal is 15 days; and
  • If you file an appeal, you must file with your FI within 120 days after overpayment is recouped.

Christopher Guadagnino, PhD, is a medical writer based in Pennsylvania.