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The RAC is back, increasing scrutiny in a complex nursing home audit environment

by Transitional Care Management

02 19, 2024 | Posted in Press | 0 comments

Sabrena McCarley

Transitional Care Management Director of Clinical Reimbursement Sabrina McCarley, MBA-SL, OTR/L, CLIPP, RAC-CT, QCP, FAOTA, offers her expertise in the following article from McKnight’s Long-Term Care News.

Audits of skilled nursing providers are likely to increase this year, with a growing number of federal and state recovery audits adding to specialized compliance reviews announced last year.

In 2023, regulators instituted audits of facilities using potentially inappropriate diagnoses of schizophrenia, as well as a new, five-claim audit of every US nursing home that was specifically meant to root out improper payments.

Now, routine audits run by the federal Medicare Fee for Service Recovery Audit Program and states looking to ensure payment accuracy through the Medicaid program are roaring back to life.

“While RAC audits practically halted during the COVID-19 pandemic, activity has picked up substantially following the end of the public health emergency,” attorney Amy Fouts wrote in BakerHostetler’s Healthcare Industry 2023 Year in Review published Thursday.

While some of the Recovery Audit Contractor activity is moving toward outpatient services, she warned inpatient providers such as skilled nursing operators to stay vigilant for more scrutiny.

So, too, does Sabrena McCarley, director of clinical Reimbursement for Transitional Care Management.

While she won’t go so far as to call any 2023 increases in RAC activity an “explosion,” she said her company and others who provide billing and compliance support to nursing homes are seeing “an increase in audits of everything.”

“The floodgates, essentially, have opened,” said McCarley, secretary of the National Association of Rehabilitation Providers and Agencies. “When you just talk about the RAC audit, people think, ‘Oh I’m totally excepted. I don’t take Medicare. I’m never going to see an audit.’ … They kind of get in this trap. They’re in a bubble, and then they don’t know what to do when their bubble bursts.”


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