Tag Archives: Recovery Audit Contractors

Medicare FFS RACs Identified Almost $2.4 Billion in Overpayments in FY 2014

According to CMS, the Medicare Fee-For-Service (FFS) Recovery Auditor Program identified and corrected $2.57 billion in improper Medicare payments in FY 2014. The lion’s share of this amount — $2.39 billion — represented overpayments collected, compared to $173.1 million in underpayments repaid to providers. Considering all program costs (other than expenses incurred at the third … Continue Reading

CMS Updates Inpatient Hospital “Two Midnight” Review Education/Enforcement Strategy

CMS recently provided an update on its education and enforcement strategies related to its “Two Midnight” policy, which addresses when surgical procedures, diagnostic tests and other treatments are generally considered appropriate for inpatient hospital admission under Medicare Part A. The Medicare Access and CHIP Reauthorization Act of 2015 generally bars recovery audit contractors (RACs) from … Continue Reading

MedPAC Report to Congress on Medicare and the Health Care Delivery System

The Medicare Payment Advisory Commission (MedPAC) has released its June 2015 Report to the Congress on Medicare and the Health Care Delivery System. The report includes a series of recommendations on Medicare hospital short-stay policy, in response in part to hospital concerns about related Medicare Recovery Audit Contractor (RAC) Program audits and appeals and the … Continue Reading

CMS Announces DMEPOS/Home Health/Hospice RAC, Improvements to RAC Process

CMS has announced that it has awarded the Region 5 Recovery Audit contract to Connolly, LLC (although the Government Accountability Office subsequently reported that a bid protest has been filed regarding this award). The purpose of this contract will be to identify improper Medicare payments for durable medical equipment (DME), orthotics, prosthetics, and supplies and home health/hospice … Continue Reading

RACs Identified $3.75 Billion in Improper FFS Medicare Payments in FY 2013

According to a new CMS report, fee-for-service (FFS) Medicare Recovery Auditors identified and corrected 1,532,249 claims for improper payments in FY 2013, representing $3.75 billion in improper payments. Of this amount, $3.65 billion was attributable to overpayments, compared to 102.4 million of the improper claims were underpayments that were repaid to providers and suppliers. According to … Continue Reading

GAO Calls for Improvements to Medicare Contractor Postpayment Review Process

The Government Accountability Office (GAO) has issued a report entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews."  In the report, the GAO assesses CMS policies and procedures to prevent certain Medicare contractors (Medicare Administrative Contractors, Zone Program Integrity Contractors, Recovery Auditors, and the Comprehensive Error Rate Testing … Continue Reading

CMS to Restart RAC Reviews

CMS has announced that, in light of the continued delay in awarding new Recovery Auditor contracts, it is modifying current contracts to allow the Recovery Audit Contractors (RACs) to restart some reviews. While CMS anticipates that most reviews will be done on an automated basis, a limited number will be complex reviews of topics selected … Continue Reading

Senate Aging Committee Calls for Medicare Audit, Local Coverage Policy Reforms

The Senate Aging Committee has released a staff report entitled “Improving Audits: How We Can Strengthen the Medicare Program for Future Generations.”  The report describes the burden audits can impose on providers, and raises concerns that CMS’s current efforts are “aimed more at identifying and recovering improper payments that have already occurred, rather than a … Continue Reading

CMS Adds MAC/RAC “Provider Relations Coordinator” for Auditor Process Issues

In an effort to “increase program transparency and offer more efficient resolutions to providers” subject to the medical review process, CMS has created the new position of “Provider Relations Coordinator."  The Provider Relations Coordinator is intended to improve communication between providers and CMS on medical review process issues. For instance, providers can contact the Provider … Continue Reading

Congressional Health Policy Hearings

A number of Congressional panels have focused on following health policy issues recently, including the following: The House Ways and Means Health Subcommittee examined various Medicare hospital issues, including the CMS two-midnights policy, short inpatient stays, outpatient observation stays, Recovery Audit Contractor audits, and the appeals backlog. The House Energy and Commerce Committee held a hearing … Continue Reading

RACs Correct $2.4 Billion in Medicare Claims in FY 2012

CMS has released data on Recovery Audit Contractor (RAC) operations fiscal year 2012. Key findings included the following: In FY 2012, Medicare fee-for-service (FFS) RACs collectively identified and corrected 1,272,297 claims for improper payments, which resulted in $2.4 billion in improper payments being corrected ($2.3 billion in overpayments/$109.4 million in underpayments). Subtracting fees, costs, and … Continue Reading

CMS Again Extends “Probe & Educate” Phase for 2-Midnight Inpatient Admissions Criteria Implementation; Clarifies Physician Certification Requirements

CMS has announced that it is extending provider education activities related to its new Medicare inpatient hospital admission and medical review criteria (commonly known as the 2-Midnight Rule). Specifically, CMS is extending what it refers to as the “Probe & Educate” review process for an additional six months, through September 30, 2014. Under this extension, … Continue Reading

CMS Limits Compliance Reviews under New “2 Midnight” Inpatient Admissions Policy

As discussed in previous reports, the final FY 2014 IPPS rule established new criteria for determining the appropriateness of inpatient admissions. In brief, under this policy, CMS generally will presume that surgical procedures, diagnostic tests, and other treatments are appropriate for Medicare Part A inpatient hospital payment when the physician admits a patient based on … Continue Reading

OIG Report Examines Medicare Appeals Volumes and Timeliness

This post was written by Nancy Sheliga. In October 2013, the OIG issued a report (“The First Level of the Medicare Appeals Process, 2008–2012:  Volume, Outcomes, and Timeliness") that addresses the first level of the appeals process for Medicare Parts A and B, known as redetermination. Eighteen contractors that process redeterminations and relevant CMS staff were contacted for … Continue Reading

OIG Seeks Improvements to RAC Program, Enhanced CMS Efforts to Stop Improper Medicare Payments

The OIG has called on CMS to strengthen activities to prevent improper Medicare payments, including enhancements to the Recovery Audit Contractor (RAC) program. For instance, the OIG notes that RACs identified half of all claims they reviewed in FYs 2010 and 2011 as having resulted in improper payments totaling $1.3 billion. While CMS took corrective … Continue Reading

Health Policy Hearings

A number of recent Congressional hearings have focused on health policy issues, including the following: The House Energy and Commerce Committee held hearings on bipartisan proposals to redesign the Medicare benefit structure and challenges facing businesses under the ACA. A June 28 hearing will focus on Medicare Part B drug program reforms. House Ways and … Continue Reading

CMS Releases FY 2011 RAC Report, RAC “Myths” Document

CMS has released a report to Congress on “Recovery Auditing in the Medicare and Medicaid Programs for Fiscal Year 2011”.  According to CMS, recovery auditors identified and corrected 887,291 claims amounting to $939.3 million in improper payments in fiscal year 2011; while most of the improper payments ($797.4 million) were overpayments, the auditors also were … Continue Reading

CMS Releases Medicare Beneficiary Ombudsman Report

CMS has released its 2011 Ombudsman Report to Congress, which describes the activities of the Office of the Medicare Ombudsman (OMO) and sets forth the OMO’s recommendations for improving beneficiaries’ experiences with Medicare. Specific recommendations to CMS cover three topics: (1) recovery of conditional payments from beneficiaries by the Medicare Secondary Payer Recovery Contractor; (2) … Continue Reading

CMS Recovery Audit Prepayment Review Demonstration to Launch Aug. 27, 2012 (Covering One Initial MS-DRG)

CMS has announced that its Recovery Audit Prepayment Review Demonstration, originally scheduled to launch on January 1, 2012, is now scheduled to begin on August 27, 2012. Under this program, CMS plans to expand the use of Medicare Recovery Auditors in the Medicare fee-for-service program to review claims before they are paid. The demonstration will … Continue Reading