Skip to main content

6 Major RAC Audit Triggers To Monitor

May 13, 2013

6 rac audit triggers to avoidNo matter how careful you are in maintaining and managing your records, since the establishment of the national Recovery Audit Program in 2006, the fear of a recovery audit is always looming in the minds of most medical practitioners and practice managers. Although you may believe your records are impeccable, even a seemingly minor or innocent oversight can draw the attention of recovery audit contractors and significantly increase the risk of an audit. Knowing how to identify these audit triggers and take steps to avoid them is one of the best ways to ensure your practice avoids the scrutiny of your local recovery auditor. Here’s a list of the six most common audit triggers to avoid:

1. Know for whom the bell curve tolls. The government loves statistics, and the folks at the Centers for Medicare and Medicaid Services are no exception. For years, they’ve used a simple bell curve to help identify practices that may be under- or over-coding Medicare and Medicaid claims. Ideally, you want to fall somewhere within that nice, bulging area of the curve – the spot where most of your colleagues wind up. If your practice shows up at either end of the curve, you can expect your chances of an audit to rise dramatically. So what does this mean to you? You need to be aware of the patterns of coding in your own practice and watch out for variations in the norm. Make sure more general codes have the documentation to support the code’s use or go the extra mile and review an additional system to see if the next highest code might apply.

2. Monitor patient complaints and handle them ASAP. Unhappy patients who call their payer’s office and complain about billing and charges can draw unwanted attention to your practice. Make sure your patients know that any billing complaints should be directed to your staff right away so charges can be explained and verified.

3. Likewise, make sure your employees are happy. A disenchanted employee can cause significant headaches with just one or two phone calls. Even though their claims may be based on malice and not on facts, you may still find yourself facing an audit. Make sure employees know they are able to discuss their work-related concerns openly and keep an eye out for employees who seem unhappy or disgruntled.

4. Keep an eye on your modifiers. Using a lot of modifiers – especially 25 and 59 – can set red flags waving and cause claims processing to stall. While the use of modifiers is certainly permitted for outliers that are clearly outside the arena of normal coding, they’re not intended for regular and repeated use; applying them in that manner can cause eyebrows to raise.

5. Avoid “cut and paste” when completing records. Having an EHR system does make life easier, but using obvious shortcuts when completing records is a big no-no. Use EHR templates as a guideline for form completion and be sure to include individual comments and descriptions unique to each patient.

6. Review your office’s compliance plans. Having an up-to-date compliance plan, including a robust billing and coding procedure, and making sure everyone follows it doesn’t just avoid potential problems – in case of an audit, it also provides powerful documentation that your practice is operating properly and above board. Don’t have a current compliance plan? There’s never been a better time to draft one.

According to the CMS website, the Recovery Audit Contractor (RAC) program was established to ensure the Medicare and Medicaid systems are used as they were intended to be used, but despite their good intentions, an audit can still be a nerve-wracking experience. Keeping an eye open for these potential triggers may help your practice avoid an audit – and just may help you gain some much–needed peace of mind.





Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch