“Hidden RAC Audits” – Seriously…

September 26, 2023
Medicare Advantage Plans

Attorney Knicole Emanuel has posted a chilling blog on her site about hidden RAC (Recovery Audit Contractor) audits. Federal regulations limit RACs from going back more than 3 years to audit claims. However, the other alphabet soup of audits (e.g., UPIC, TPEs, SMRCs, OIG, etc.) are allowed more than a 3-year lookback period – and some are long lookback periods (like the OIG). Ms. Emanuel points out that when a vendor negotiates with a Medicare provider to get one of these audit contracts, they negotiate what kind of audit entity they will be.

A vendor may be hired by CMS to be a RAC auditor, but, once the vendor realizes the limit of 3 years on the lookback period, it can go back to CMS and asks if it can be considered an UPIC. Why? “A UPIC can do everything that a RAC does; however, it gets an additional 3 years to look back at claims and that means money.” That has huge monetary implications.

Caroline Fife, MD

Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.

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