Why is there a RAC focus on One Day Stays?
A. There are a handful of reasons for the RAC audits focus on cardiac related One Day Stays. First, CMS has spent a lot of time & money on establishing evidence-based outcomes for chest pain and chest pain related cardiac diagnoses. Second, every prior CMS study has shown a disproportionate share of medically unnecessary (or those not meeting clinical payment criteria) admissions for cardiac patients – the latest CERT reports show $300M in overpayments for One Day Stay cardiac-related cases. Third, the estimated Medicare payment difference between handling a chest pain case as an inpatient versus an outpatient is $2,740 / case. Q. Are RAC Auditors really “Bounty Hunters”? A. No. RAC auditors are medical collection companies or “recovery” firms hired by CMS to do a job. They are specifically contracted to enforce CMS evidence-based coverage policies and CMS payment criteria for billing and claims submission. RAC audits do differ from PSC audits, ZPIC audits and Medicaid Integrity audits
