Question 1

Once an improper payment is identified, the RAC would contact the provider and notify them of an overpayment that they received. They would look to collect that amount from the provider, or an underpayment that the provider received from CMS and pay that amount to the provider. This process is called:

Accepted Answer

A

Question 2

The central part of the __________________________ is to request the medical records for the patient's stay that is in question. The medical records will assist the RAC in determining if there was an overpayment or underpayment.

Accepted Answer

The central part of the Complex Review process involves requesting the patient's medical records to assist the Recovery Audit Contractor (RAC) in determining if there was an overpayment or underpayment. This is because a Complex Review requires detailed examination of records to make accurate payment determinations.

Question 3

The Third Level of Appeal is established when at least _____ remains in controversy following a Qualified Independent Contractor (QIC) decision. A request for reconsideration through an Administrative Law Judge (ALJ) hearing must be filed within 60 days of receipt of the reconsideration decision.

Accepted Answer

The Third Level of Appeal, which involves a hearing before an Administrative Law Judge (ALJ), is established when at least $160 remains in controversy following a Qualified Independent Contractor (QIC) decision. This threshold ensures that only disputes involving a significant amount of money proceed to this level of appeal.

Question 4

The Fourth Level of Appeal is when an organization or party is unhappy with the ALJ decision and may request a review by the Appeals Council. This request must be submitted within ____ days of receipt of the ALJ's decision and must specify the issues and findings that are being contested.

Accepted Answer

The correct answer is 60 days. This is the timeframe within which an organization or party must request a review by the Appeals Council after receiving the decision from the Administrative Law Judge (ALJ).

Question 5

Since the inception of the Comprehensive Error Rate Testing Program (CERT), CMS has reduced improper payments from 9.8% in 2003 to 3.9% in 2007.

Accepted Answer

The Comprehensive Error Rate Testing (CERT) Program was implemented by CMS to measure improper payments in the Medicare fee-for-service program, and it successfully reduced the improper payment rate from 9.8% in 2003 to 3.9% in 2007.

Question 6

This RAC program was designed to establish whether or not this type of program would be a cost-effective means of adding resources to determine if correct payments were being made from Medicare to various providers and suppliers.

Accepted Answer

The RAC (Recovery Audit Contractor) program was indeed designed to identify and correct improper Medicare payments through the review of provider and supplier billing, thus aiming to ensure that the right payments are made to healthcare providers and suppliers for Medicare-covered services.

Question 7

Most importantly, RAC contractors are paid via a contingency fee that is based on the amount of improper payments that they correct for both overpayments and underpayments.

Accepted Answer

Recovery Audit Contractors (RACs) are paid on a contingency fee basis, which means their payment is based on the amount of improper payments they identify and correct, including both overpayments and underpayments.

Question 8

The goal of the program is that, even with paying a contingency fee to the RAC auditors, the integrity of the Medicare Trust Funds would be maintained. CMS, during the demonstration phase of this project, committed to addressing some concerns raised along with identifying successes and opportunities for improvement.

Accepted Answer

The answer of The goal of the program is that,...

Quiz 14: Recovery Audit Contractors