Understanding the Medicare Recovery Audit Contractor (RAC) Program for Part A Providers. Donna Gilley Practice Leader, Healthcare Consulting Lattimore Black Morgan & Cain, PC. MORE THAN YOU EXPECT. EVERYTHING YOU NEED. What is the RAC Program?.
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Practice Leader, Healthcare Consulting
Lattimore Black Morgan & Cain, PC
MORE THAN YOU EXPECT...
EVERYTHING YOU NEED
What is the RAC Program? Program for
RACs (Recovery Audit Contractors) are third-party contractors hired by CMS to analyze post payment provider Medicare claims and in some cases the associated medical record in an attempt to detect and correct past improper payments.
CMS has divided the country into four geographic locations and awarded contracts to different organizations for of these locations.
4 RACs Named
Region A 12.45% contingency rate Diversified Collection Services, Inc. (DCS) 333 North Canyons Parkway, Suite 100 Livermore, CA 94551-7661
Region C 9% contingency rateConnolly Consulting Associates, Inc. (Connolly)50 Danbury RoadWilton, CT 06897
Region B 12.50% contingency rateCGI Technologies and Solutions, Inc. (CGI) 11325 Random Hills RoadFairfax, VA 22030-6051
Region D 9.49% contingency rateHealthDataInsights, Inc. (HDI)7501 Trinity Peak Street, Suite 120Las Vegas, NV 89128-6896
Medically Unnecessary – Payments are made for services that were not medically necessary or did not meet the Medicare medical necessity criteria for the setting where the service was rendered
(e.g., a claim from a hospital for three colonoscopies for the same beneficiary on the same date of service. Only one colonoscopy per day is medically necessary.)
Part A Claims Program for Considered Improper Payment if…
Incorrectly Coded – Payments are made for services that are incorrectly coded (e.g., the provider submits a claim for a certain procedure but the medical record indicates that a different procedure was actually performed.)
Insufficient/No Documentation – Providers fail to submit documentation requested or fail to submit enough documentation to support the claim
Top Services with Overpayments Program for
Inpatient Rehabilitation Facility
Top Services with Overpayments Program for
Skilled Nursing Facility
The program is permanent
Hospital can send rebuttal to RAC within 15 days of determination, RAC can either change determination or provider can move to Appeals Process
Five Levels of Appeal:
AHA RAC document Program for
What Will be the New Normal Now? Program for
2008 Midyear CERT report Program for
Designed to manage the provider’s appeal process to the RAC auditor and the denial of medical claims
- CRM and Task Management
- Configurable Parameters
- Upload Claim History
For each claim under audit:
Donna Gilley is a healthcare professional with over 20 years experience in medical operations and financial consulting services, and she leads the Healthcare Regulatory Compliance practice at Lattimore Black Morgan & Cain. Her areas of expertise span the healthcare Revenue Cycle including billing office assessment and redesign, patient access policy and re-engineering, Federal, state, and local compliance initiatives, HIPAA privacy, medical coding and billing, Stark & anti-kickback regulations, and reimbursement methodologies including Medicare’s Resource Based Relative Value System (RBRVS). With a background including medical practice administrator and director level positions with several of the nation’s largest hospital corporations, she has experience in multiple disciplines of medicine in the physician clinic, ambulatory surgery, and hospital settings. By focusing her practice on healthcare compliance, Donna has become a sought after professional on a number of healthcare legal issues. She has served as an expert compliance witness in a high-profile federal litigation case regarding improper coding practices, and most recently served as the expert witness in a case involving federal reimbursement of medical devices and associated rebates. She serves on several healthcare editorial advisory boards (including Cigna Medicare) and is a well known speaker on a variety of topics at local and national healthcare conferences annually.