RACs are able to choose the issues that they audit. The issues they select and have approved by CMS must be listed on their website. Unlike in the demonstration project, the RACs are allowed to audit for level of service related to E/M codes.
Typically, the RAC will choose issues to audit for based on information provided by CMS to the general public. Specifically, we expect that RACs will make their decisions on issues for auditing based on documents such as the Office of Inspector General’s Work Plan, reports from the Comprehensive Error Rate Testing (CERT) program, and others that identify issues where fraud is frequently committed or errors are commonly made.
The RACs are not able to create their own rules for coding, billing and coverage. Instead, they must conduct their reviews based on the Medicare rules, available to the public in statute, regulation and the Medicare Internet-Only Manuals. With respect to questions and reviews for medical necessity, the RACs have medical and coding professionals on staff to assist in making determinations.
For more information about the RACs, both the demonstration and the permanent program, visit CMS’ RAC resource page.
To access the Medicare Internet-Only Manuals, visit CMS’ manuals page.