compliance
2nd Nov

On October 31, 2016, The Centers for Medicare & Medicaid Services (CMS) reported on their RAC Website that they have awarded new round of contracts for the Medicare Fee-for-Service Recovery Audit Contractors (RACs).

The mission of the RAC program is to identify and correct Medicare improper payments through detection and collection of overpayments made on claims for services provided by providers with the goal of preventing future improper payments in the United States. This program is a result of the Prescription Drug, Improvement, and Modernization Act of 2003 demonstration. This demonstration enabled additional review of Medicare claims by Recovery Auditors (RAs) on a contingency fee basis to identify and investigate claims with a calculated risk. This demonstration proved that RAs were successful in the identification and prevention of improper payments.

How does it work? The RA review process consists of datamining of post-payment claims and then review by RAs. Review types include Automated-no medical record review, Semi-Automated- data and review of medical record, and Complex: full medical record review.

New issues and vulnerabilities are posted on the RAC website. The RAs can look back three years from the date the claim was paid. Once the review is completed, the RAs will offer an opportunity for the provider to discuss the improper payment. This discussion is prior to the normal appeal process.

The agency identified the awarding of contracts to the following:

  • Region 1 – Performant Recovery, Inc.
    • Will perform post-payment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice
  • Region 2 – Cotiviti, LLC
  • Will perform post-payment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice
  • Region 3 – Cotiviti, LLC
  • Will perform post-payment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice
  • Region 4 – HMS Federal Solutions
  • Will perform post-payment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice
  • Region 5 – Performant Recovery, Inc.
  • Dedicated to the post-payment review of DMEPOS and Home Health/Hospice claims nationally.
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