RAC Prepayment Reviews of Medicare Claims Are Coming
I. Introduction: As you know, RACs play an important role in the identification of Part A and Part B overpayments. Since the inception of the RAC Demonstration Project in 2005, RACs have successfully identified a number of improper claims, denying payment for reasons ranging from mere technical errors to broad concerns about medical necessity. Unlike other contractors engaged in post-payment audits (such as Zone Program Integrity Contractors and Program Safeguard Contractors), RACs are not compensated on a fixed contract or cost-plus basis. Instead, their compensation is based on the amount of overpayments they identify (which remain overpayments after any administrative appeals ...
RAC Audits to be Extended to Medicaid — HHS Publishes Proposed Rules on Medicaid Recovery Audit Contractors Further Highlighting the Question, Is a Claim Ever Final? Providers Need to Understand and Take an Active Role in the Process.
(December 17, 2010): The U.S. Department of Health and Human Services (HHS) recently published a Proposed Rule which extends the Recovery Audit Contract (RAC) process to claims under the Medicaid program. As background, the RAC process has been a part of the Medicare program since 2005, first as a demonstration project from 2005 – 2008, and then extended to the entire nation effective no later than January 1, 2010. Under the Medicare RAC program, HHS retains private contractors for a post payment review process to identify over and under payments on a contingency fee basis. There are two types of reviews ...
CMS Authorizes Medicare Contractors to Accept Administrative Appeals by Facsimile and Secured Internet Transmission but Many Contractors have Yet to Implement this Change
(December 14, 2010): Earlier this year, the Centers for Medicare and Medicaid Services (CMS) issued Change Request (CR) 6958, titled “Guidelines to Allow Contractors to Develop and Utilize Procedures for Accepting and Processing Appeals Via Facsimile and/or Via a Secure Internet Portal/Application.” Health care providers and their counsel welcomed the guidance, anticipating that this change would make it easier when filing requests for redetermination and reconsideration. To its credit, CMS authorized Part A and Part B Medicare Administrative Contractors (MACs), Durable Medical Equipment MACs, Fiscal Intermediaries, Carriers and Regional Home Health Intermediaries (RHHIs) to accept administrative appeals by facsimile and / ...
Points to Consider When a ZPIC Extrapolates Alleged Damages
Imagine a ZPIC, PSC, or RAC hands you a claims analysis rife with alleged errors, an indecipherable list of statistical formulas, and an extrapolated recovery demand that will cripple your practice or clinic. What steps should you take to analyze their work? Based on our experience, providers can and should carefully assess the contractor’s actions, use of formulas and application of the RAT-STAT program when selecting a statistical sample and extrapolating the alleged damages based on the sample pulled. Over the years, we have challenged the extrapolation of damages conducted by Medicare contractors around the country, covering tens of thousands ...
Region D RAC (Health Data Insights) Begins Medical Necessity Reviews
(August 30, 2010): Introduction: Health Data Insights (HDI), the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) responsible for auditing health care providers in Region D, has announced it will immediately begin reviews on previously approved projects which involve the medical necessity of selected inpatient DRG payments. A complete list of the medical necessity “issues” currently being examined by HDI can be found on its Website. Scope of Responsibility: RACs, such as HDI, contract with the CMS to perform post-payment reviews of Medicare claims to find overpayments (and theoretically, underpayments in return for a percentage (from 9 percent to 12.5 ...
Region B RAC CGI Announces that it will Begin Review of Eighteen Projects that Involve Medical Necessity
CGI Technologies and Solutions, Inc., (CGI), has announced it will immediately begin reviews on 18 newly approved projects that involve the medical necessity of selected inpatient DRG payments. A complete list of the issues currently being examined by CGI can be found on its website. http://racb.cgi.com/Issues.aspx Recovery Audit Contractors (RACs), such as CGI, contract with the Centers for Medicare & Medicaid Services (CMS) to perform post-payment reviews of Medicare claims to find overpayments and underpayments in return for a percentage (from 9 percent to 12.5 percent) of the amounts recovered. Put simply, they eat only what they kill. CGI was awarded ...
Look at RACs — Part III: What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?
(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. In Part II, we discussed some ways providers can prepare for and respond to an audit request. In this Part III, we will discuss a provider’s appeal options in the event that a RAC identifies an alleged overpayment as a result of its audit. It is important to remember that ...
A Look at RACs — Part II: How Should Physicians and Other Providers Respond to a RAC Audit?
(June 28, 2010): In Part I of this series, we reacquainted you with the design and purpose of the now permanent Recovery Audit Contractor (RAC) Program. Although RACs largely focused on inpatient care during CMS’ demonstration program, RACs are a real threat to small providers that don’t have the intensive compliance programs in place that most hospitals do. In this Part II, we will look at how physicians, home health, hospice, and durable medical equipment (DME) suppliers can prepare for and respond to RAC audits. Even if no demands are issued, the RAC audit process exposes providers to substantial risks and ...
A Look at RACs — Part I: What Do Physicians, Home Health, Hospice, and DME Providers Need to Know?
(June 25, 2010): The purpose of this series of articles is to assess the Recovery Audit Contractor (RAC) Program from the perspective of physicians, home health, hospice, durable medical equipment (DME) providers, and other relatively small Medicare providers. As many non-hospital providers will acknowledge, early cries of wolf by law firms and consultants did a fine job of initially publicizing the RAC threat. Unfortunately, the threat of a RAC audit now appears to be largely ignored by non-hospital providers due to the seemingly widespread sense that RACs will likely continue to focus their efforts on large, institutional Medicare providers – ...
HHS-OIG report “Recovery Audit Contractors’ Fraud Referrals.”
(February 20, 2010): Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, directed the Secretary, HHS to conduct a demonstration project using Recovery Audit Contractors to identify and recoup Medicare overpayments. Unlike Program SafeGuard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) agreements, RACs were not tasked with performing benefit integrity functions (e.g. identifying and reporting health care providers believed to be committing fraud). In fact, CMS did not even train RACs participating in the demonstration projects on how to identify and report possible instances of fraud. As set out in HHS-OIG’s report “Recovery Audit Contractors’ Fraud Referrals” ...
RAC News
RAC Prepayment Reviews of Medicare Claims Are ComingI. Introduction: As you know, RACs play an important role in the...
RAC Audits to be Extended to Medicaid — HHS Publishes Proposed Rules on Medicaid Recovery Audit Contractors Further Highlighting the Question, Is a Claim Ever Final? Providers Need to Understand and Take an Active Role in the Process.(December 17, 2010): The U.S. Department of Health and Human Services (HHS) recently...
Region D RAC (Health Data Insights) Begins Medical Necessity Reviews(August 30, 2010): Introduction: Health Data Insights (HDI), the Centers for Medicare...
Region B RAC CGI Announces that it will Begin Review of Eighteen Projects that Involve Medical NecessityCGI Technologies and Solutions, Inc., (CGI), has announced it will immediately begin...
HHS-OIG report “Recovery Audit Contractors’ Fraud Referrals.”(February 20, 2010): Pursuant to the Medicare Prescription Drug, Improvement, and...
Read More Posts From This CategoryMedicare Audits
RAC Prepayment Reviews of Medicare Claims Are ComingI. Introduction: As you know, RACs play an important role in the...
CMS Authorizes Medicare Contractors to Accept Administrative Appeals by Facsimile and Secured Internet Transmission but Many Contractors have Yet to Implement this Change(December 14, 2010): Earlier this year, the Centers for Medicare and Medicaid Services...
A Look at RACs — Part II: How Should Physicians and Other Providers Respond to a RAC Audit?(June 28, 2010): In Part I of this series, we reacquainted you with the design and...
A Look at RACs — Part I: What Do Physicians, Home Health, Hospice, and DME Providers Need to Know?(June 25, 2010): The purpose of this series of articles is to assess the Recovery...
Read More Posts From This CategoryMedicare Guidance
Points to Consider When a ZPIC Extrapolates Alleged DamagesImagine a ZPIC, PSC, or RAC hands you a claims analysis rife with alleged errors, an indecipherable list of statistical formulas, and an extrapolated recovery demand that will cripple your practice or clinic. What steps should you take to analyze their work? Based on our experience, providers can and should carefully assess the contractor’s actions,... [Read more of this review]
Look at RACs — Part III: What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. ... [Read more of this review]
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