The Provider's #1 Resource - Medicare RAC Audits & RAC Appeals
Medicare RAC Appeals & Legal Services / Medicare Compliance & Clinical Reviews / Medicare Fraud & Abuse
Contact Us For Immediate Assistance - (303) 586-5003 or support@racaudits.com
Castle Rock Medical Group 100% Unconditional Compliance Guarantee - RAC Audits & Appeals Castle Rock Medical Group provides the nation's most efficient & effective professional services solution for the evaluation of RAC audit focus areas and the submission of RAC audit appeals. CRMG absolutely and unconditionally guarantees enhanced CMS compliance by our clients. If CRMG provides formal guidance, consulting or legal services relating to CMS payment criteria – and our client adheres to formal CRMG guidance – CRMG will defend the provider at no additional cost throughout the first 4 levels of the CMS appeals process including – Rebuttal, Redetermination, Reconsideration and the Administrative Law Judge hearing. This Unconditional Compliance Guarantee is offered for clients under professional services contracts for RAC audit medical reviews & assessments, RAC audit appeals and a wide range of similar CRMG compliance services. Please contact us directly for contract terms & conditions at (303) 586-5003. CRMG Clinical, Compliance & Legal Services - RAC Audits & Appeals
CMS is combining Medicare RAC audits with pay-for-performance (p4p) initiatives in a classic "carrot and stick" approach to advancing and solidifying evidence-based medicine as the foundation for the future of the Medicare program. CRMG professionals work with hospitals, inpatient rehabilitation facilities, physician practices and health law firms nationwide in a wide range of Medicare RAC consulting focus areas: To speak directly with one our CRMG's Medicare consultants, clinical auditors or Medicare lawyers - or for questions regarding Medicare RAC Audit consulting, RAC appeals or RAC legal services - please contact us directly at (303) 586-5003 or compliance@racaudits.com.
CRMG's Medicare RAC audit clinical & billing assessments (or "Mock Audits") are centered on CMS payment criteria and traditionally include a pre-determined sampling of 100 - 500 patient encounters. Each encounter is pre-screened and carefully selected based upon the RACs initial primary focus areas and outcomes in each of the 3 demonstration states as well as the Health System's specialty profile (i.e. Cardiology, Vascular, Ortho, Inpatient Rehab, etc.).
Medicare RAC Audits & RAC Appeals - Medicare Clinical & Compliance Reviews
Outstanding RAC References - Proven RAC Results - Unparalleled RAC Appeals Expertise
CRMG's experienced clinical auditors and Medicare compliance professionals team with the industry's leading health law firms and Medicare lawyers to provide a seamless consulting and legal services solution including - CMS clinical and billing case reviews, case review appeals summaries, required CMS documentation and submission of appeals starting with the initial stage of RAC appeals process.
To speak directly with one of CRMG's Medicare consultants, clinical auditors or Medicare lawyers - or for questions regarding CMS efforts to stop Medicare fraud & abuse, CMS audits, CMS appeals, RAC audit clinical and billing assessments, Medicare RAC audit documentation, Medicare RAC appeals, RAC appeal attorneys or other Medicare compliance services - please contact us at (303) 586-5003 or support@racaudits.com.
Medicare Clinical & Compliance Reviews - RAC Audits & RAC Appeals
Castle Rock Medical Group (a Jackson Davis HealthCare company) is the nation's leading provider of RAC clinical & compliance reviews, RAC appeals and RAC legal services. CRMG has completed Medicare RAC medical & billing compliance assessments and provided RAC appeals support for providers ranging in size from $8.5B multi-hospital health systems and major academic medical centers to inpatient rehabilitation facilities and $25M critical access hospitals.
CRMG is the leading national resource for RAC clinical & compliance reviews, CMS payment criteria documentation, CMS billing compliance, Medicare appeals & legal advisory services. Comprised of board-certified physicians, nurses, billing compliance professionals and former hospital executives - we are widely recognized as the nation's leading expert on Medicare RAC audits and RAC appeals. Although the RAC audit target issues may vary based upon a hospital's reimbursement structure, CMS payment criteria are applicable across the spectrum.
We absolutely and unconditionally guarantee that our clients are at the forefront of insuring compliance with CMS payment criteria, reducing Medicare fraud and adhering to medical necessity requirements.
Medicare Concurrent Compliance Review - RAC Audit Focus Areas
Medicare RAC Audit Clinical & Compliance Assessments - Hospital
Medicare RAC Audit Clinical & Compliance Assessments - Inpatient Rehabilitation
Medicare RAC Audit Clinical & Compliance Assessments - Physician Services
Medicare RAC Audit Appeals
2009 RAC Audits & Appeals Guide
2009 RAC Self-Audit & RAC Appeals Tools
Clinical Documentation & Coding Compliance Management
Case Management / Utilization Review / Discharge Planning
Charge Master and Medicare Cost Report Compliance
RAC Task Force Development and Audit Tracking Processes
Hospitals, physicians and other healthcare providers are facing the imminent adoption of Medicare's new evidence-based reimbursement structure, implementation of wide ranging EBM policies & procedures and the introduction of concepts such as evidence-based coverage, pay-for-performance and value-based purchasing. In order to insure compliance and make a clean break from the past, CMS is using high-profile RAC audits to force the implementation of evidence-based standard of care practices.
Claims and opinions of RAC audits & the RAC appeals process being buried in subjectivity and vague interpretations of medical necessity couldn't be farther from the truth. Outdated notions and concepts of "soft" Medicare billing and claims submission requirements have been left in the past. The game has changed - very real and defined CMS payment criteria, required documentation and the application of CMS evidence-based outcomes rule-the-day.
Hospitals, inpatient rehabilitation facilities and physicians have all felt the initial impact of RAC audits in California, New York & Florida - $980.0M in recovered payments, hospital & inpatient rehabilitation facility closures and massive physician practice operating losses. RACs have won over 93% of overpayment determinations and 66% of all appeals. CMS payment criteria are well documented and a wide range of operational changes by providers can be effectively implemented to insure ongoing compliance.
Medicare Clinical & Compliance Assessments (RAC "Mock Audits")
Specific focus areas traditionally include:
One-Day Stays - Chest Pain & GI Diagnoses
Respiratory Care Diagnoses with Ventilator MS-DRGs
Excisional Debridement Impacted MS-DRGs
Extensive O.R. Procedures Unrelated to PDX
PCI / Implantable Cardioverter Defibrillators (ICDs)
SNF Admissions & 3-Day Acute Stay Medical Necessity
Emergency Room Visits and Modifier 25
Discharge Status Code Assignment
Inpatient Rehabilitation Facility Admissions
Based upon the number of records being reviewed and scope of the RAC audit focus areas, CRMG's Medicare RAC Audit assessments are traditionally completed over a 2 - 8 week time frame. Each in-depth evaluation incorporates a stratified sampling of Medicare RAC audit focus areas and includes 3 major assessment components - billing, coding structure & medical necessity. All CRMG RAC audit & RAC appeals services include detailed evaluations by our board-certified physicians, nurses, case management specialists, legal services staff, Medicare reimbursement and billing compliance professionals.
CRMG's experienced Medicare consultants, Medicare lawyers, RAC audit and RAC appeals staff, physicians, nurses and former hospital executives are all dedicated to providing you with an unmatched professional services experience. Each assessment finding is supported by an extensive & wide range of formal documentation resources authored by or reviewed on behalf of the Centers for Medicare & Medicaid Services.
SAMPLE "MOCK" RAC AUDIT ASSESSMENT COMPONENTS
(7 of 12 actual work plan steps)
Based upon the specific RAC area under review, consider both the Hospital's internal admission criteria and evidence-based coverage policies adopted by CMS, individual state / regional QIOs and external third-parties such as InterQual, Milliman, etc.
Based upon the pre-determined sampling of encounters and the primary RAC focus area under consideration, perform a detailed review of medical records documentation, patient billing statements & paid UB92/04 claim forms for each encounter
Evaluate the accuracy and sequencing of ICD-9 principal diagnosis, secondary diagnoses and ICD-9 procedures for the provision of covered medical services and the initial determination of medical necessity
Based upon supporting medical record documentation, documented diagnoses, ICD-9 procedures and established MS-DRG grouping criteria, review MS-DRG assignments and determine appropriateness and applicability of claim-level MS-DRG designations
Review hospital Charge Master and evaluate a wide range of detailed charge and claim level coding considerations including areas such as covered & non-covered charges, CPT / HCPCS code assignment & billing units, National Revenue Codes, GL revenue & expense matching, etc.
Perform detailed Inpatient Rehab Facility medical record evaluation in order to identify variances related to established CMS payment criteria, medical necessity guidelines, required documentation elements, Case Management effectiveness, etc. (inpatient rehab only)
Develop a detailed, comprehensive RAC assessment for review by legal counsel and hospital senior management. Assessment will include all detailed outcomes of the medical records evaluation, anticipated financial impact of RAC challenges, statistical validity of the evaluation and copies of all supporting documentation relating to CRMG’s review.