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Physician RAC Vulnerabilities Detailed in CMS Release

James Carroll, for HealthLeaders Media, December 14, 2010

Continuing its efforts to publicize valuable information derived from the RAC demonstration, CMS released on December 2 the fourth in a series of MLN Matters articles.

The latest, Special Edition article SE1036, provides education on two high-risk vulnerabilities for physician claims. According to CMS, these claims were denied because the demonstration RACs determined that either a duplicate claim was billed and paid, or the physician reported an incorrect number of units for current procedural terminology (CPT) code billed based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy. Examples include:

Other services with excessive units—Units billed exceeded the number of units per day based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy. (Pre-appeal improper payment amount: $6,635,558)


Duplicate Claims—Physician billed and was paid for two claims for the same beneficiary, for the same date of service, same CPT code, and same physician. (Pre-appeal improper payment amount: $1,094,751

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