CCT Government Audits and RACs 2 — Questions and Answers
Question 1: Which entity administers the Recovery Audit Contractor (RAC) program on behalf of CMS?
- The Office of Inspector General (OIG)
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- The Department of Justice (DOJ)
- The Government Accountability Office (GAO)
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the RAC program and contracts with private auditors to identify improper Medicare and Medicaid payments.
Question 2: What is the maximum look-back period that a RAC can use when reviewing Medicare fee-for-service claims?
- 1 year
- 2 years
- 3 years (Correct answer)
- 5 years
Correct answer: 3 years
RACs are generally limited to a 3-year look-back period from the date the claim was paid.
Question 3: A RAC identifies a claim as a potential overpayment but has not yet issued a demand letter. What is this stage called?
- Automated review
- Complex review
- Discussion period (Correct answer)
- Extrapolation
Correct answer: Discussion period
The discussion period allows providers to submit additional documentation or discuss findings with the RAC before a formal demand is issued.
Question 4: Which type of RAC review requires human review of medical records before an improper payment determination is made?
- Automated review
- Semi-automated review
- Complex review (Correct answer)
- Statistical sampling review
Correct answer: Complex review
Complex reviews involve a clinical review of medical records and are used when automated data analysis alone cannot confirm improper payment.
Question 5: When a RAC issues an overpayment demand letter, within how many days must a provider file a redetermination request with the MAC to begin the appeals process?
- 30 days
- 60 days
- 120 days
- 180 days (Correct answer)
Correct answer: 180 days
Providers have 120 days from receipt of the initial determination (demand letter) to file a redetermination request at Level 1 of the Medicare appeals process.
Question 6: In the context of RAC audits, what does 'underpayment' mean?
- A claim paid at a lower rate than the Medicare fee schedule
- A payment made to an ineligible provider
- An instance where Medicare paid less than it should have under the rules (Correct answer)
- A claim denied due to lack of medical necessity
Correct answer: An instance where Medicare paid less than it should have under the rules
RACs can identify both overpayments and underpayments; an underpayment occurs when Medicare paid less than the correct amount under applicable rules.
Question 7: Which government program specifically targets Medicaid fraud, waste, and abuse through state-level audits, separate from the federal RAC program?
- Medicaid RAC (MIC) program (Correct answer)
- ZPIC program
- CERT program
- MAC program
Correct answer: Medicaid RAC (MIC) program
The Medicaid RAC (formerly MIC) program requires states to contract with auditors to identify Medicaid improper payments, analogous to the Medicare RAC program.
CCT Government Audits and RACs 2
Which entity administers the Recovery Audit Contractor (RAC) program on behalf of CMS?