Department of Medicine, School of Medicine, Vanderbilt University, Nashville, Tennessee 37232, USA.
J Am Geriatr Soc. 2010 Aug;58(8):1576-8. doi: 10.1111/j.1532-5415.2010.02974.x. Epub 2010 Jul 19.
Knowledge of Medicare policies and procedures is integral to the practice of geriatric medicine. Within the past several years, there has been a focus on Medicare fraud, abuse, and waste in healthcare spending. One program, Medicare Recovery Audit Contractors (RAC), has recently been launched to identify improper payments by performing postpayment reviews of Medicare Part A and Part B claims. During the program pilot project in only three states, more than $1 billion in incorrect payments were identified, with the overwhelming majority being overpayments that had to be returned to the Medicare Trust Fund. In 2006, Congress mandated that the RAC program be rolled out nationwide, which is ongoing. The audit focuses on documentation of medical necessity for inpatient admission and the 3-day qualifying stay for skilled nursing care, important concerns for geriatricians. This article describes the RAC program and target areas for payment recoupment, denials management, and provider preparation.
了解医疗保险政策和程序是老年医学实践的重要组成部分。在过去几年中，医疗保险在医疗支出方面的欺诈、滥用和浪费问题一直备受关注。最近推出了一项名为医疗保险恢复审计承包商（RAC）的计划，通过对医疗保险 A 部分和 B 部分的报销进行事后审查，以确定不当支付。在仅三个州的试点项目中，发现了超过 10 亿美元的不正确支付，其中绝大多数是超额支付，必须返还给医疗保险信托基金。2006 年，国会授权在全国范围内推出 RAC 计划，该计划正在进行中。审计的重点是对住院和 3 天资格护理的医疗必要性的文件记录，这是老年病医生关注的重要问题。本文介绍了 RAC 计划以及付款追回、拒绝管理和提供者准备的目标领域。
