A Comparison of the Medicaid and Medicare Recovery Audits

While the words “fraud and abuse” may have diminished in use, they have been replaced with the latest catch phrases “improper payments” and “recovery audits.” Both Medicare and Medicaid are active in their efforts to remain true to their agency’s survival during this financial crisis through the audit processes.

 

While we are on the front end of the audit implementation, it is a good time to compare the nuances of the audits and better prepare ourselves for addressing time lines, audit issues and appeal processes for the federal agencies. But don’t forget, OIG audits and third-party payer audits are not going away. Everyone is enforcing their agendas as providers try to maintain their revenue cycle daily activities and keep up with audits.

First, the similarities between all the various payer audits that providers are juggling are less daunting than the differences, so let’s start easy with a comparison.

 

Table 1 delineates the similarities while Table 2 notes the basic differences. However, please note that these are not the only comparisons.

While many are developing home grown electronic tracking tools in order to avoid missing deadline and others are purchasing audit software from vendors, the OIG and various insurance companies are surprising all of us with their random audits and requests. 

 

Remember the old saying that the devil is in the details? In the case of RACs and MICs, it truly is the little things that can result in major problems that haunt us. 

Needless to say, there are many, many comparisons that could be explored on the topic of auditor guidelines and specifications and we have only addressed a baker’s dozen. No doubt we need to re-address RACs and MICs toward the end of the year when we all have had a chance to experience them live.