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CMS Center For Program Integrity (CPI) Part D Recovery Audit Contractor (RAC) Program Overview PowerPoint PPT Presentation


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CMS logo. CMS Center For Program Integrity (CPI) Part D Recovery Audit Contractor (RAC) Program Overview . Tanette Downs and Frank Chartier Division of Plan Oversight & Accountability. Image of spilled med capsules. RAC Overview Agenda Topics. RAC Program History and Background

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CMS Center For Program Integrity (CPI) Part D Recovery Audit Contractor (RAC) Program Overview

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Cms center for program integrity cpi part d recovery audit contractor rac program overview

CMS logo

CMS Center For Program Integrity (CPI)Part D Recovery Audit Contractor (RAC) Program Overview

Tanette Downs and Frank Chartier

Division of Plan Oversight & Accountability

Image of spilled med capsules


Rac overview agenda topics

RAC Overview Agenda Topics

  • RAC Program History and Background

  • Part D RAC Audit Process

    • Pre-Audit Phase

    • Audit Phase

    • Post-Audit Phase

    • Questions

2


History and background of the recovery audit contractor rac program

History and Background of the Recovery Audit Contractor (RAC) Program

  • The RAC program was congressionally mandated to identify improper payments and recoup overpayments

  • The RAC program is responsible for:

    • Identifying and correcting past improper payments to Medicare providers and Medicare Advantage (MA) and Prescription Drug (PD) Plans

    • Implementing procedures to help CMS, MA and PD Plans, Medicare Carriers, Fiscal Intermediaries, and Medicare Administrative Contractors (MACs) implement actions to prevent future improper payments

  • CMS’ Center for Program Integrity (CPI) currently oversees the Medicare Prescription Drug “Part D” RAC program

3


History of part d and the medicare rac program

History of Part D and the Medicare RAC Program

  • Part D, the Medicare Prescription Drug Benefit, was enacted via Title I of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) (P.L. 108-173) in December 2003

  • The FFS RAC program was implemented as a demonstration project through The Tax Relief and Health Care Act of 2006

  • CMS permanently implemented the FFS RAC program on a nationwide basis in October 2009

  • Signed in 2010, Section 6411(b) of the Affordable Care Act (ACA) expanded the use of RACs to Medicare Parts C and D

4


Part d rac program roles

Part D RAC Program Roles

Part D RAC

ACLR Strategic Business Solutions

http://aclrsbs.com

Center for Program Integrity

Data ValidationContractor (DVC)

Livanta

www.livanta.com

Contract Oversight

Part D RAC Outreach & Education StrategicHealthSolutions, LLC www.strategichs.com

5


The part d rac program

The Part D RAC Program

The Part D RAC:

  • Analyzes previously paid individual Medicare Part D claims/ Prescription Drug Events (PDEs) and other financial information

  • Corrects past improper payments to Medicare Part D Plans

  • Provides information to CMS to help prevent future improper payments

  • Refers any potential fraud findings identified during the auditing process to the MEDIC, CMS’s contracted field agent that assists with detection and prevention of fraud, waste and abuse in the Parts C and D programs

6


Rac overview agenda topics1

RAC Overview Agenda Topics

  • RAC Program History and Background

  • Part D RAC Audit Process

    • Pre-Audit Phase

    • Audit Phase

    • Post-Audit Phase

    • Questions

7


Part d rac program audit phases

Part D RAC Program Audit Phases

  • Pre-Audit: CMS determines audit criteria and scope to conduct audits of previous Medicare Part D payments

  • Audit: The RAC conducts improper payments analyses and impact calculations and notifies the Part D Plan of the findings, including the demanded amount

  • Post-Audit: Identified improper payments are collected from Part D Plans. If an Plan feels the RAC findings are in error, this is also the phase in which a Plan is provided opportunity to appeal

    Each of these audit phases is discussed in greater detail in the following slides

8


Rac overview agenda topics2

RAC Overview Agenda Topics

  • RAC Program History and Background

  • Part D RAC Audit Process

    • Pre-Audit Phase

    • Audit Phase

    • Post-Audit Phase

  • Questions

9


Cms audit issues

CMS Audit Issues

CMS mandates review of contracts by issue type for a specified audit year and audit issue

Planned Part D RAC audit issues include:

  • Excluded Providers: The Part D RAC reviews PDE records submitted for Part D drugs prescribed and filled by providers who were excluded from Medicare at the time of the claim

  • Duplicate Payments: The Part D RAC reviews PDEs submitted for the same beneficiary, same medication for the same or closely matching dates

  • Direct and Indirect Remuneration (DIR): The Part D RAC reviews information submitted to CMS regarding DIR to determine whether amounts reported and used for reconciliation match supporting documentation and actually-incurred costs

10


New issues review board nirb

New Issues Review Board (NIRB)

Additional audit issues may be proposed through the New Issues Review Board (NIRB)

  • The NIRB is a multi-member entity within CMS

    • Considers potential audit issues and their potential suitability for the RAC program

  • CMS, the RAC, Plans and other stakeholders are encouraged to submit as many potential audit issues as desired to the NIRB for consideration

  • CPI leads the NIRB and reaches out to additional Subject Matter Experts (SMEs) within CMS, as appropriate

11


Rac overview agenda topics3

RAC Overview Agenda Topics

  • RAC Program History and Background

  • Part D RAC Audit Process

    • Pre-Audit Phase

    • Audit Phase

    • Post-Audit Phase

    • Questions

12


Rac s multi step p rocess outline

RAC’s Multi-Step Process Outline

13


The rac audits steps

The RAC Audits Steps

  • Step 1: Obtain Supporting DocumentationThe RAC must obtain the appropriate documentation from CMS

  • Step 2: Review PDEs or Other Data Needed to Conduct the AuditAfter the documentation is compiled, the RAC can conduct analyses and impact calculations on audit data to identify improper payments

14


The rac audits steps1

The RAC Audits Steps

  • Step 3: Request Additional InformationIf an improper payment is identified, the RAC may send a Request For Additional Information (RFI) to Plans

  • Step 4: Prepare IPRPAfter the RAC identifies an improper payment, it compiles an IPRP, which contains the audit issue, audit year and contract number along with supporting documentation identifying the impacted PDE records that support improper payment findings

15


The rac audits steps2

The RAC Audits Steps

  • Step 5: Perform Data Analysis CheckThe Data Validation Contractor (DVC) receives the IPRP and performs an analysis of the IPRP along with a sample of the associated PDE records

  • Step 6: Create Validation Findings FileThe DVC creates an IPRP Validation Findings file which includes its analysis and supporting documentation; along with a status of its findings

16


The rac audits steps3

The RAC Audits Steps

  • Step 7: Resolve RAC/DVC Findings DisputesIf the DVC and the RAC cannot resolve a dispute; the RAC shall notify CMS. CMS is the final decision maker to resolve disagreements on improper payment findings between the DVC and the RAC after they have exhausted all other means

17


The rac audits steps4

The RAC Audits Steps

  • Step 8: Send Notification of Improper Payment Letter Specifying Amounts OwedOnce the IPRP has been submitted and validated, a Notification of Improper Payment Letter is formally sent to the Part D Plans specifying the amount of improper payments identified, the process for payment and information regarding appeal

18


Rac overview agenda topics4

RAC Overview Agenda Topics

  • RAC Program History and Background

  • Part D RAC Audit Process

    • Pre-Audit Phase

    • Audit Phase

    • Post-Audit Phase

    • Questions

19


Rac post audit

RAC Post Audit

RAC will remain involved for Post Audit issues:

  • Notification of Improper Payments Letters are sent and identified improper payments are collected from Plans

  • Appeal and payment information will be sent along with Notification of Improper Payment Letter

  • RAC will assist CMS on appeal issues

20


Rac post audit1

RAC Post Audit

Payment Adjustment Process

  • Interim adjustments made to monthly payment

  • Adjustment recouped at contract level

  • Adjustment credited to the contract during the re-opening of reconciliation

21


Rac post audit2

RAC Post Audit

Part D RAC Outreach & Education

  • Conduct educational activities

  • Facilitate dissemination of information

  • Educate Part D Plan sponsors about audit and appeals issues

22


Rac post audit3

RAC Post Audit

RAC Audit Issues Appealable:

  • Determination that an overpayment was made

  • Amount of the overpayment

  • RAC findings and support

23


Rac post audit4

RAC Post Audit

Audit Issues NOT Appealable

  • The methodology and standards used to identify and calculate the overpayment(s)

  • PDEs submitted by the Part D Plans subsequent to the final reconciliation for plan year 2007

  • Any issues other than those identified in the NIP letter

  • Any issues related to re-openings

24


Rac post audit5

RAC Post Audit

Supporting Evidence for Appeal is documentation indicating:

  • An excluded provider/prescriber obtained an OIG waiver (Social Security Act § 1128(c)(3)(B))

  • An excluded provider/prescriber rendered a service or item under exigent circumstances (42 C.F.R. § 1001.1901(c)(5)(i))

  • An excluded provider/prescriber rendered a service or item during a Federal disaster or other public health emergency declaration (Social Security Act § 1135(b))

25


Rac post audit6

RAC Post Audit

Appeals are submitted by e-mail to:

  • Level I: Request for Redetermination

    • [email protected]

    • [email protected]

  • Level II: Request for Reconsideration

    • [email protected]

26


Rac post audit7

RAC Post Audit

Medicare Part D RAC Appeal Timeline

27


Resources

Resources

  • Medicare Parts C and D

    Recovery Audit Program

    website

    http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program-parts-c-and-d/

  • General questions or

    guidance on redetermination

    and Reconsideration

    PartD [email protected]

28


Rac overview agenda topics5

RAC Overview Agenda Topics

  • RAC Program History and Background

  • Part D RAC Audit Process

    • Pre-Audit Phase

    • Audit Phase

    • Post-Audit Phase

    • Questions

29


Questions

Questions

30


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