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RAC Learning Series Part Four – Demystifying the Query (Audit) Process

Demystifying the Query (Audit) Process Vickie Axsom-Brown, Senior Consultant, BHM Healthcare Solutions Demystifying the Query Development process is key to every health care provider’s success regardless of the type of services delivered.  It requires an understanding of the resources, references and tools used by RACs so providers can maintain their organization’s preparation for CMS audit “participation.” The tools used by RACs are vast and may look like alphabet soup.  The “New Issue” process begins with the responsible team’s identification of potential billing/reimbursement issues.  The typical “New Issues” team is comprised of experienced claims’ processing representatives with Part A, Part B, DME, pharmacy, home health, hospice, hospitals, providers, SNFs, et. al. specific backgrounds. This team uses their experience and multiple resources to identify potential issues for which analysis will be done to validate issue value.   In addition to experience, the following data sources are used (the alphabet soup):   Raw Data – RAC database, routine CMS RAC Data Warehouse downloads, industry trends… Outcome Reports – CERTs[i], OIG[ii], PEPPER[iii], GAO[iv], QIOs[v]…. Industry Experience[vi] & Information –

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