HIM 205 - Competency Assignment RAC Analysis

Questions
1. Why are facilities and providers unable to prevent the improper claims that the RACs have identified in their reviews? Facilities and providers are unable to prevent the improper claims that the RACs have identified in their reviews because of their inability to comply with CMS guidelines on filing medical claims. As a result, the providers are like to submit wrongfully coded claims, applications for services that do not meet the CMS criteria and discrepancies between services provided and the supporting documents. Codes are also susceptible area where the provider submits the wrong code for a specific treatment. The RAC has the necessary technology including a data warehouse and information system that picks up the errors. Also they enlist medical professionals who help them investigate claims by providing their professional input on the concern at hand.

2. What can providers and facilities learn from this report? 

3. What key points can be identified and then implemented at the coder, physician, and clinician level to improve reporting processes?