CMS Recovery Audit Contractors (RAC)
Posted On 14-Oct-2008
The Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractors (RAC) program to address fraud concerns has been announced. The program will initially start with four contractors in selected states and will include all the states nationwide no later than 2010. The RAC program mission is to detect and correct past improper payments and to implement actions to prevent further improper payments. Claims with unusually high volume or high dollars will be examined and visits to the providers may also be warranted.
The four RACS listed below begin their work on a contingency fee basis on October 1, 2008:
- Diversified Collection Services, Inc. of Livermore, California, in Region A
Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and New York
- CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B
Michigan, Indiana, and Minnesota
- Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C
South Carolina, Florida, Colorado, and New Mexico
- HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D
Montana, Wyoming, North Dakota, South Dakota, Utah, and Arizona
California, Texas, Nevada, and Oklahoma will be added on March 1, 2009, and the other states will be added on August 1, 2009, or later.
CMS will roll out the program with an emphasis on provider education and is working towards resolving the appeals process which was an issue from the demonstration program last year.
RACs must document a targeted area they would like to review and CMS will decide if RACs can conduct the review.
CMS will limit the number of medical record requests RACs make of providers in one month, and will also limit the look-back period to October 1, 2007. Additionally, each RAC is required to hire a physician medical director and coder before they begin claims analysis.
In order to address some of the concerns of the provider community, CMS made numerous alterations to the initial RAC demonstration project. One of the changes includes the creation of a CMS review board, which will be in place to streamline the appeal process.
Review of evaluation and management services will be included in the RAC program. Documentation verifying the levels of service selected by coders will be checked.
The RACs will have a claim status Web site on which they will post all medical requests. This will allow the opportunity for everyone to be aware of the issues and vulnerabilities.
The GAO will report back on the RAC rollout.
