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Medicare Recovery Audit Contractor (RAC) Program

Medicare Recovery Audit Contractor (RAC) Program. Jennifer Amann, MBA Healthcare Resource Providers, LLC. Recovery Audit Contractors. Goal: Identify overpayments and underpayments made by CMS to providers Four contractors hired by Medicare to conduct audits

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Medicare Recovery Audit Contractor (RAC) Program

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  1. Medicare Recovery Audit Contractor (RAC) Program Jennifer Amann, MBA Healthcare Resource Providers, LLC

  2. Recovery Audit Contractors • Goal: Identify overpayments and underpayments made by CMS to providers • Four contractors hired by Medicare to conduct audits • Regional rollout started in March 2009 • Scheduled to involve all 50 states by 2010 • Paid based on “savings” to Medicare program • Incentive to find incorrect overpayments

  3. RAC Contractors • Diversified Collection Services, Inc. (A) • www.dcsrac.com • CGI Technologies and Solutions, Inc. (B) • www.racb.cgi.com • Connolly Consulting Associates, Inc. (C) • www.connollyhealthcare.com • HealthDataInsights (D) • www.racinfo.healthdatainsights.com

  4. RAC Websites • Sample audit request letters • List of approved issues for review • Example: Diversified Collection Services • 7 Inpatient hospital issues (most DRG related) • 11 DME • 1 Ambulance providers • 1 Clinical social workers (CSW) • Detailed descriptions and policy-related links provided • Radiology procedures currently most likely to be pulled in from inpatient hospital issues

  5. Medical Record Review • RACs must have a physician medical director and certified coders • Must provide credentials upon request • No audits on claims paid before 10/1/2007 • Limited to 3-year retrospective review • CMS sets limits per year • Covers the number of medical records that can be requested per 45-day period

  6. Medical Record Review Limitations • 2009 limits for Part B providers • 10 records for solo practitioners • 20 for 2-5 physicians • 30 for 6 -15 physicians • 50 for groups of 16 or more • Number of records can be adjusted annually • No updates for 2010 published yet

  7. RAC Letters • Specify coverage, coding or payment policy violated • Reason for review • Description of overpayment situation • Recommended corrective actions • Explanation of: • Provider’s right to submit a rebuttal statement prior to recoupment of overpayments • Procedures for recovery of overpayments • Right to request extended repayment schedule • Right to appeal • Other requirements for written notifications

  8. Audit Process • Typically practices will receive letters requesting medical records • Auditors have authority to go on site to view and copy records • Practices can refuse access, however • RAC then needs to provide written request for copies

  9. Educational Resources • Watch for RAC contractor outreach activities • Several have scheduled presentations at industry association meetings • CMS has announced series of free educational teleconferences • April 28, 2010 • RAC 101 • May 12, 2010 • RAC 101 for Physicians • Calls scheduled 1:00 – 2:30 EST • 877-251-0301

  10. Preparing for the RAC • What were the results of recent CERT audits? • Track coding and medical necessity denials for patterns • Conduct internal coding audits • What was ordered was what was done • What was done was what was billed • What was billed was what was paid

  11. The Bigger Picture • Overall Medicare auditing/enforcement actions • CERT • ZPIC (Medicare Zone Program Integrity Contractors) • RAC • ZPIC compliance efforts (assigned based on MAC jurisdictions) • Data analysis and data mining • Medicare reviews to support “benefit integrity” • Supporting law enforcement and answering complaints • Investigating fraud and abuse • Recommending recovery of Federal funds through administrative action • Referring cases to law enforcement

  12. Thank you! Jennifer Amann, MBA Healthcare Resource Providers, LLC P.O. Box 90190 Albuquerque, NM 87199 Cell: 817-406-3355 jkroken@radconsultants.com www.radconsultants.com

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