RACs Identify High-Risk Vulnerabilities for Physicians

Recent RAC audits have detected two high risk vulnerabilities for physician claims are listed in Table 1 below. These claims were denied because the demonstration RACs determined that either a duplicate claim was billed and paid or the physician reported an incorrect number of units for Current Procedural Terminology (CPT) code billed based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy.

Item Provider Type Improper Payment Amount (pre-appeal) RAC Demonstration Findings
1 Physician $6,635,558 Other Services with Excessive Units - Units billed exceeded the number of units per day based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy.
2 Physician $1,094,751 Duplicate Claims - Physician billed and was paid for two claims for the same beneficiary, for the same date of service, same CPT code, and same physician.

For more information, go to:

http://www.cms.gov/mlnmattersarticles/downloads/se1036.pdf

 

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