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Zusatztext For many nurse leaders! understanding the mysteries of corporate compliance! the Office of the Inspector General! or the Department of Justice has been challenging to say the least. Dr. Duane Abbey has taken these topics and! specifically! the newest kid on the compliance block-the Recovery Audit Contractor (RAC) Program-and translated them into a very understandable language that nursing leaders can get their arms around! particularly in the surgical arena. ? Although the subject is potentially intimidating! this book is a very engaging and understandable read for nurse leaders. As an experienced leader but one who is a novice in compliance matters! I found that the author provides this book as a tool kit to help leaders find the information necessary to proactively prepare for a RAC audit. The author does a great job of taking the technical language related to RAC audits and incorporating the use of storytelling to explain the important concepts in an understandable and engaging format. Not surprisingly! the author has more than 25 years of health care experience! with much of his time spent divided between teaching the concepts of billing and compliance and consulting with health care organizations.-Maureen C. Chadwick! MSN! RN! NE-BC! Director! Peri-Operative Services! Saint Vincent Health Center! in the AORN Journal! May 2011! Vol. 93! No. 5 Informationen zum Autor Duane C. Abbey Zusammenfassung Medicare fraud is big business, but while only a few profit from intentional malfeasance, the Centers for Medicare & Medicaid Services is now taking a closer look at everyone. This title explains all that is required to prepare and successfully defend against inappropriate RAC audit recoveries. Inhaltsverzeichnis Acronym ListingChapter 1 IntroductionSynopsisConventions Used throughout the BookChapter 2 Purpose! Structure! and Intent of the RAC Audit ProgramIntroductionRAC Demonstration ProjectSelection and Utilization of RACsCMS and the RAC OperationsPayment of the RACsSummary and ConclusionChapter 3 RAC! OIG! and Medicare AuditsIntroductionGeneral Categories of AuditsMedicare AuditsOIG and DOJ AuditsMedicare CERT ProgramOIG Guidance: Federal RegisterRAC AuditsWhat Happened to the Underpayments?CMS's Approach for the RACsSummary and ConclusionChapter 4 Brief Review of Healthcare Payment and Payment SystemsIntroductionClaims Adjudication RequirementsCovered Individual/Covered ServicesProper Orders with Appropriate Diagnostic JustificationQualified Facility or PractitionerAppropriate DocumentationMedicare Billing PrivilegesCorrect Claim! Filed TimelyMedicare Payment SystemsMedicare Fee SchedulesMedicare Prospective Payment SystemsMedicare Payment System InterfacesSummary and ConclusionChapter 5 RAC Audit IssuesIntroductionUnderlying Compliance AreasMedical NecessityPayment System InterfacesInadequate GuidanceConfusing GuidanceSample Problem Areas by Provider TypeHospitalsCritical Access HospitalsPhysicians and ClinicsOther Healthcare ProvidersSummary and Future IssuesChapter 6 RAC ProcessesIntroductionProblem Identification! Data Mining! and Probe AuditsAutomated ReviewsComplex ReviewsExtrapolationRAT-STATS ExampleStratified SamplingUsing Extrapolation in ReverseSummary and ConclusionChapter 7 Understanding the RAC Appeals ProcessIntroductionAppeals ProcessRAC DiscussionRequest for RedeterminationReconsiderationAdministrative Law JudgeMedicare Appeals CouncilFederal District CourtPursuing the Appeals ProcessDeveloping Organizational ResourcesCase DevelopmentHierarchy of Medicare GuidanceClarifying GuidanceAmbiguous GuidanceIncorrect GuidanceRequesting Guidance and the Federal RegisterCoding/Billing versus Adjudication/PaymentDirectives Inherent in the Payment SystemInterpretation of GuidanceOther IssuesMMA 2003 Protection ProvisionsAddressing Extrapolation CasesSummary and ConclusionChapter 8 Meeting the RAC Audit ChallengeIntroductionReviewing and Assessing Current...
