Recovery Audit Contractor

News & Analysis as of

D.C. Circuit Declines Hospitals’ Plea for Relief from CMS Catch-22

Here’s how the catch works. A hospital admits and treats a Medicare patient who needs care. The hospital bills Medicare and gets paid. Later—usually much later—a RAC auditor rules that the patient needed only outpatient care...more

Health Headlines: Also in the News - September 2014

GAO Finds CMS Should Fully Develop Plans for Medicare Advantage Encounter Data and Assess Data Quality Before Use – In a report released on September 2, 2014, GAO evaluated CMS’s plans for using Medicare Advantage (MA)...more

Federal Court Rejects Challenge to new CMS Recovery Auditor Contracts

On August 22, 2014, the U.S. Court of Federal Claims denied a challenge by incumbent Recovery Audit Contractor (RAC) CGI Federal, Inc. (CGI) to CMS’s plan to award new RAC contracts. Among other things, the Court found that...more

RAC Program to Resume Limited Reviews

On August 4, 2014, the Centers for Medicare and Medicaid Services (CMS) announced that it would allow the Recovery Audit Contractor Program (RAC) to resume a limited number of reviews in August. The program has been dormant...more

GAO Issues Report on Post-Payment Claims Reviews by CMS Contractors

The U.S. Government Accountability Office (GAO) recently issued a report entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Post-Payment Claims Reviews,” which...more

AHA Renews Complaints about OIG Hospital Compliance Reviews

The American Hospital Association (AHA) has renewed its complaints about OIG “hospital compliance reviews.” Last Thursday AHA Executive Vice President Rick Pollack sent a letter to Health & Human Services Secretary Burwell...more

Efforts to Stop Health Insurance Fraud Through Use of Contractors Under Fire

In recent reports, from June 25, 2014 and August 13, 2014, the Government Accountability Office (GAO) highlights the mixed results achieved by the federal government's increased efforts to crack down on health insurance fraud...more

How the US Government is cracking down on Medicare fraud

Medicare fraud is a major problem in the United States, with estimates of fraud and systematic overcharging totaling $60 billion each year. That’s nearly five times the cost of healthcare fraud in Canada, and makes up a...more

Who Audits the Auditors?

Since the advent of Medicare in 1965, hospitals have bemoaned the cost and burden of Medicare audits. The complaints increased when CMS hired private contractors for the audits. They became deafening in 2009 with the advent...more

Brace Yourself: The RACs Are Back

Under the controversial program private contractors audit hospitals and other Medicare providers for fraudulent and erroneous Medicare billing. Why is it controversial? Because the auditors are paid a percentage of...more

RAC Program Update: CMS Appoints Provider Relations Coordinator

On June 2, 2014, CMS posted a brief update on its Recovery Audit Contractor (RAC) program website announcing the creation of a “Provider Relations Coordinator” position within CMS. The announcement states that the role of...more

Recently Released Data Show Current Status and Future of Medicare Integrity Efforts

Last week, CMS and the Government Accountability Office (GAO) published two reports concerning Medicare contractor developments. In the Medicare Fee for Service National Recovery Audit Program Quarterly Newsletter, CMS...more

Medicare Audit and Appeals: A Study in Utter Dysfunction

Facing a backlog of over 350,000 appeals from payment demands issued by Recovery Audit Contractors (RAC's), the Center for Medicare and Medicaid Services ("CMS") has effectively given up and announced that its Office of...more

OMHA's Medicare Appellant Forum Offers Few Meaningful Answers for Frustrated Medicare Providers and Suppliers

On February 12, 2014, the Office of Medicare Hearings and Appeals ("OMHA") hosted a Medicare Appellant Forum ("Forum") to address its current backlog of appeals. OMHA is responsible for hearings before Administrative Law...more

More Than 100 House Members Urge HHS to Reform RACs

A bipartisan group of 111 members of the United States House of Representatives sent a letter to HHS Secretary Kathleen Sebelius on February 10, 2014, urging the Secretary to reform the Medicare Recovery Audit Contractor...more

Streamlined RAC Appeal Processes Lead To Winning Legal And Economic Outcomes

Armed with the Recovery Audit Contract (RAC) Program, the Federal government has been very successful in recouping Medicare overpayments from health care providers in recent years. During a RAC audit, program contractors...more

Congress Passes FY14 Spending Bill, Includes Important Healthcare Provisions

On January 16, 2014, the U.S. Senate passed an omnibus spending bill for FY 2014 that includes several important healthcare provisions, and President Obama signed the legislation the following day on January 17, 2014. ...more

OIG Releases Study on Medicare RAC Performance, Says Contractors Recovered $1.3 Billion in FYs 2010 and 2011

OIG recently published a study analyzing the performance of Medicare Parts A and B Recovery Audit Contractors (RACs) in fiscal years (FYs) 2010 and 2011. OIG said that it conducted the study to evaluate CMS’s oversight of...more

United States Senate Committee on Finance Holds Hearing Regarding Oversight of Recovery Audit Contractors

On June 25, the Senate Finance Committee held a hearing to address the Medicare Recovery Audit Contractor (RAC) Program. Committee members expressed concern that the RAC program creates unreasonable administrative burdens...more

PRIME Act: New Legislation to Curb Health Care Fraud

The United States Senate and House of Representatives recently introduced bipartisan legislation designed to reduce fraud, waste, and abuse in the Medicare and Medicaid programs. The legislation, entitled “Preventing and...more

RAC Relief (Sort Of)

CMS announced that it would reduce the number of additional documentation requests (ADRs) available to its Recovery Audit Contractors (RACs). ...more

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

CMS Issues Revised Provider and Supplier ADR Limitations

On April 3, 2013, CMS issued revised provider and supplier additional documentation request (ADR) limitations for the Recovery Audit Contractor (RAC) program. The revised provider ADR limitations are effective April 15,...more

Annual Report Shows Meteoric Rise in RAC Activity

On February 5, 2013, CMS issued its mandatory Recovery Audit Contractor (RAC or Recovery Auditor) program annual report, detailing overpayments, underpayments, RAC performance and savings to the Medicare program. According to...more

Dealing with RAC Audits and Denials: How Healthcare Providers Can Manage Medicare Recovery Efforts

Executive Summary: Medicare RAC (Recovery Audit Contractor) audits are becoming increasingly aggressive, creating delays in payment for healthcare providers. Certain strategies can help mitigate delays caused by RAC audits...more

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