Recovery Audit Contractors and Two Institutions' Response to Audit Requests Regarding Medicare Total Joint...

The Centers for Medicare & Medicaid Services Recovery Audit Program identifies and corrects Medicare improper payments through the detection and assessment of overpayments and underpayments. Recovery audit contractors (RACs) conduct postspayment reviews at the system and individual levels. We report on two institutions' results with RAC audits for total joint arthroplasty (TJA) for medical necessity and documentation requirements.

There were 210 (138 academic medical center [AMC] and 72 community-affiliated hospital [CH]) Medicare TJA cases audited by RACs from June 21, 2022, to June 23, 2023, in six separate inquiries (46, 24, 22, 46, 38, and 24 cases). There were 92 (66 AMC and 26 CH) total hip and 118 total knee arthroplasty (72 AMC and 46 CH) cases audited. Of the 138 audited cases at the AMC, all were appealed, and seven were denied payment. Of those seven, one was overturned and released for payment, while six were denied payment. Of the 72 cases audited at the CH, all were released for payment with no findings.

There were 210 cases audited by RACs; 6 (2.8%) were denied payment. After the initial review of 46 cases with six denials, all subsequent audits were resolved successfully. After the initial audits, we used a templated note for the decision to pursue surgery, which included the Centers for Medicare &Medicaid Services criteria for exhausting conservative care, and included these criteria in our preoperative history and physical. Our subsequent responses to the RAC audits were successful in reversing all audits (100%, 92) after the initial 46. There was a major improvement in final acceptance and denial rates among AMC and CH audits after the implementation of interventions.

Using a collaborative approach with our Billing and Documentation team to standardize documentation of surgical decision-making and preoperative conservative care, we minimized the financial impact of RAC audits of our TJA patients at an AMC and CH.