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Medicare Recovery Audit Contractors (RACs)

Medicare Recovery Audit Contractors (RACs). George Mills Director, Provider Compliance Group Office of Financial Management Centers for Medicare & Medicaid Services. 1. What is a RAC? RAC Program Mission.

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Medicare Recovery Audit Contractors (RACs)

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  1. MedicareRecovery Audit Contractors (RACs) George Mills Director, Provider Compliance Group Office of Financial Management Centers for Medicare & Medicaid Services 1

  2. What is a RAC?RAC Program Mission • The RACs will detect and correct past improper payments so that CMS and the Carriers/FIs/MACs can implement actions that will preventfuture improper payments • Providers can avoid submitting claims that don’t comply with Medicare rules • CMS can lower its error rate • Taxpayers and future Medicare beneficiaries are protected 2

  3. RAC Jurisdictions A D B March 1, 2009 March 1, 2009 August 1, 2009 C 3

  4. RAC Legislation Medicare Modernization Act, Section 306: required the 3-year RAC demonstration Tax Relief and Healthcare Act of 2006, Section 302: requires a permanent and nationwide RAC program by no later than 2010 Both statutes gave CMS the authority to pay RACs on a contingency fee basis 4

  5. RAC Review Process • RACs review claims on a post payment basis • RACs use the same Medicare policies as FIs, Carriers and MACs • NCDs, LCDs & CMS manuals • Two types of review: • Automated (no medical record needed) • Complex (medical record required) • RACs will NOT be able to review claims paid prior to October 1, 2007 • RACs will be able to look back three years from the date the claim was paid • RACs are required to employ a staff consisting of nurses, therapists, certified coders & a physician CMD 5

  6. RAC Program’s Three Keys to Success • Minimize Provider Burden • Ensure Accuracy • Maximize Transparency 6

  7. Minimize Provider Burden • Limit the RAC “look-back period” to three years • Maximum look back date is October 7, 2007 • RACs will accept imaged medical records on CD/DVD (CMS requirements coming soon) • Limit the number of medical record requests 7

  8. Ensure Accuracy • Each RAC employs: • A physician medical director • Certified coders • CMS’ New Issue Review Board provides greater oversight • RAC Validation Contractor provides annual accuracy scores for each RAC • If a RAC loses at any level of appeal, the RAC must return the contingency fee 8

  9. Maximize Transparency • New issues are posted to the web • Vulnerabilities are posted to the web • RAC claim status web interface (2010) • Detailed Review Results Letter following all Complex Reviews 9

  10. What Can Providers Do to Get Prepared? • Know where previous improper payments have been found (OIG, CERT, Demo RAC Reports); • Know if you are submitting claims with improper payments; • Prepare to respond to RAC medical record requests; • Appeal when necessary; • Learn from your past experiences 10

  11. Contact InformationRAC@cms.hhs.govCMS Websitewww.cms.hhs.gov/RAC 11

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