AMednews.com
REPORTS HERE that "the Centers for Medicare & Medicaid Services is
working to expand its recovery audit contractor program to all of
Medicare and to the Medicaid program by the end of the year, although an
agency official told Congress in July that CMS faces challenges in
getting that done on time."
"RACs are third-party auditors hired by CMS to comb through Medicare
claims from hospitals, physicians and others to identify improper
payments. A three-year RAC demonstration program that launched in
California, Florida and New York in 2005 identified roughly $1 billion
in Medicare overpayments, according to CMS."
"A permanent, nationwide RAC program now operates under
fee-for-service Medicare, but provisions of the new health system reform
law mandate a permanent expansion to Medicare Advantage, the Medicare
drug benefit and Medicaid by Dec. 31."
"Expansion of the RAC program to Medicaid is particularly challenging...because it involves coordination with 50 different state
programs....the agency is furthest along with
implementing a RAC component to oversee Medicare Part D, the
prescription drug program for seniors."
"RAC executives ...said they welcomed the
additional workload and would be ready to work with CMS on expanding the
program. Auditors are paid based on the dollar amount of any improper
payments they uncover." 'This may sound self-serving, but we are ready to take on more work,'
said Lisa Im, CEO of Performant Financial Corp., a firm based in
Livermore, Calif., that worked with CMS on the demonstration project. 'This contract implementation is just the beginning but has great
potential to succeed in returning dollars to the CMS. Moreover, the
application of recovery audit contracting across other federal agencies
has strong potential.'"
"Earlier this year, President Obama called for expanding payment
recapture audits throughout the federal government to improve payment
accountability."
"...a
March report from the Government Accountability Office....concluded that the Medicare agency had used
auditors to identify payment system vulnerabilities that lead to
overpayments, but it had not implemented corrective actions for 60% of
the most significant vulnerabilities. Those systemic problems
represented $231 million of the roughly $1 billion in improper payments
discovered by the contractors, GAO concluded."
"CMS said in response to the report that it was taking steps to
resolve coordination issues and address payment system vulnerabilities
through the national, permanent RAC program. Congress directed CMS to
have permanent RACs in place by 2010 to review Medicare claims from all
50 states, a goal the agency said has been met."
"CMS' Taylor also noted that several concerns raised by physicians
during the demonstration were valid, and that changes have been made to
the permanent RAC program to address them. For example, every audit firm
is now required to hire a physician medical director, which she said
gives doctors additional assurance that reviews of claims based on
medical necessity are handled properly."
"...physician organizations
have been critical of the RAC program. They say it is particularly
burdensome for physician practices to comply with the audits even when
the reviews turn up little or no evidence of Medicare overpayments. Some
physicians who were audited during the demonstration project said some
reviews appeared to be fishing expeditions to find overpayments, with
demands for scores of medical records from several years past."
