Attorney Knicole Emanuel has published another fascinating blog! Check out her discussion about the Recovery Audit Contractor (RAC) and the False Claims Act (FCA). Many practitioners are undergoing the full alphabet soup of Medicare audits (TPE, UPIC, SMERC, RAC, etc.). Current targets include the use  of “skin substitutes” (CTPs), debridement and hyperbaric oxygen therapy (HBOT).

Here’s an excerpt:

“RACs conduct audits through a variety of mechanisms, including automated reviews (for clear errors such as incorrect coding or unbundling) and complex reviews (for more nuanced issues such as medical necessity). Once RACs identify overpayments, they request that healthcare providers return the excess funds. However, their findings are limited to overpayment recovery—they do not issue findings related to violations of the False Claims Act.

Juxtapose the FCA, which is a federal law that imposes liability on entities or individuals who knowingly submit false claims for payment or approval to the government. In the context of Medicare and Medicaid, this can involve submitting claims for services that were never provided, services that were medically unnecessary, or services that were incorrectly coded. When RACs identify an overpayment, they may flag the issue for further investigation, but they do not have the authority to pursue allegations of fraud or violations of the FCA.

For example, if a provider intentionally bills for services that were not rendered or submits a claim for a higher level of service than what was actually provided (upcoding), these actions could trigger both an overpayment assessment by a RAC and a potential FCA violation. The distinction lies in whether the action was knowingly fraudulent.

…While RACs can flag overpayments, they cannot directly assert violations of the False Claims Act. This is typically the responsibility of law enforcement agencies, including the U.S. Department of Justice (DOJ) and the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS).”

Read her entire article. She mentions a CTP code sometimes used in “wound care,” but it is a code for a myocutaneous flap, which apparently is a focus of RAC auditors.

Caroline Fife, M.D.

Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos

The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.