decisionhealth Newsletters, Part B News - 2012 Issue 8 (August)
Pre-payment RAC audits may derail payment, require extra documentation
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Article Overview
This article covers a CMS Recovery Audit Contractor (RAC) pre-payment review demonstration that began in selected states and initially focused on claims tied to short hospital stays. It is relevant to physicians, compliance staff, and billing teams because it discusses how the review process may affect payment timing, claim documentation, and related administrative workflows. The article also outlines the general types of audit preparation and denial-response topics raised by experts, including record requests, review timing, and documentation monitoring.
Why This Topic Matters
Providers and billing teams need to understand how pre-payment audit activity can affect claim processing, documentation readiness, and cash flow, especially when services are connected to hospital admissions or observation stays.
Article Sections
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Program overview and launch details
Summarizes the CMS demonstration program, where it will be implemented, and the general claims time period under review. It also introduces the early focus of the review activity.
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Key elements of the demo project
Outlines the administrative features of the pre-payment review process, including timing, records handling, and how the review workflow is expected to operate.
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Pre-payment audit survival tips
Reviews general preparation themes for practices that may be affected by related claim scrutiny. The section emphasizes audit readiness, documentation monitoring, and response planning.
What You Will Learn
- How the CMS pre-payment review demonstration is structured at a high level
- Which kinds of claim workflows may be most affected by the audit process
- What administrative steps practices should monitor when responding to audit requests
- How providers may prepare documentation and internal audits for related claim reviews
- What general issues may arise when appealing a pre-payment denial
Who Should Read This
- Physician practices
- Billing and coding staff
- Compliance officers
- Hospital revenue cycle teams
- Healthcare auditors
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