The Centers for Medicare and Medicaid Services (CMS) has issued revised provider and supplier additional documentation request (ADR) limitations for the Medicare Recovery Audit Contractor (RAC) program. According to the guidance, which became effective April 15, 2013, Medicare RACs may request a minimum of 20 records in a 45-day period from hospitals, down from the previous minimum of 35 records. The maximum number of record requests per 45 days remains at 400. Hospitals with more than $100 million in MS-DRG payments still have a cap of 600.

CMS also changed limitations on the type of claims RACs can review. Previously, 100 percent of a RAC’s record request could be used toward a single type of claim, such as inpatient or outpatient. Now, RACs can only select up to 75 percent of any claim type for review, while the remaining 25 percent would have to be for other types of claims. CMS does say, however, that Medicare RACs may request permission from CMS to exceed the established ADR caps.

Click here to read the new guidance.

This CMS Issues Revised ADR Limitations for Medicare RAC Program was first published on Medicaid RAC | HMS.

A new website, www.properpayments.org, has been launched to highlight contractor efforts to fight fraud, waste, and abuse in the nation’s healthcare programs. The website is the effort of the American Coalition for Healthcare Claims Integrity, which is made up of Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs), and Medicaid Integrity Contractors (MICs). The website highlights facts about fraud, waste, and abuse in the healthcare system and acts as a hub for program integrity resources, news, and current issues.

To receive up-to-date program integrity information from properpayments.org, follow them on Twitter at @ProperPayments.

This New Website Highlights Anti-Fraud, Waste, and Abuse Efforts was first published on Medicaid RAC | HMS.

A recent House Energy and Commerce Subcommittee on Health hearing discussed fraud, waste, and abuse in Medicare and Medicaid. During the hearing Peter Budetti, Deputy Administrator and Director, Center for Program Integrity, Center for Medicare and Medicaid Services (CMS), testified about efforts to reduce improper payments. Budetti gave an overview of the Fraud Prevention System, which has saved $3 for every $1 spent, and highlighted states’ efforts to reduce improper Medicaid payments by implementing Medicaid RAC contracts. He also discussed several efforts CMS has made to collaborate with other organizations, including the creation of a public-private partnership to help fight fraud.

More information about the hearing, including testimony from Mr. Budetti, can be found here.

This Congressional Hearing Focuses on Fraud, Waste, and Abuse was first published on Medicaid RAC | HMS.

CMS has released its FY2011 RAC Report to Congress. The annual report confirms the success of the Medicare RAC program and indicates that Medicare RACs collected $797.4M in overpayments from hospitals and other providers and repaid $141.9M in underpayments. After fees, the Medicare RAC program saved Medicare more than $488M in 2011.

HDI, a subsidiary of HMS Holdings, led all other Medicare RACs by collecting $318M in overpayments in 2011.

Click here to read CMS’ report.

This Medicare RAC Program a Resounding Success in FY2011 was first published on Medicaid RAC | HMS.

The sequester that went into effect March 1, 2013 will affect efforts to curb fraud, waste, and abuse in our nation’s healthcare system. According to a report by the Office of Management and Budget (OMB), $57 million has been cut from the Health Care Fraud and Abuse Control Program (HCFAC), which is designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud, waste, and abuse. HCFAC is administered by the Department of Health and Human Services (HHS) and, according to a recent report to Congress, has an ROI of $7.90 for every $1 spent and saved $4.2 billion in taxpayer dollars during FY2012. CMS Deputy Administrator Peter Budetti, who is director of the agency’s Center for Program Integrity, recently testified before a House Energy and Commerce Health Subcommittee hearing and indicated cuts will negatively affect all programs intended to combat fraud and improper payments.

This Sequester Will Affect Fraud, Waste, and Abuse Efforts was first published on Medicaid RAC | HMS.

Earlier this year the Department of Health and Human Services (HHS) and Department of Justice (DOJ) released the FY2012 Health Care Fraud and Abuse Control Program (HCFAC) report. The report indicates that the government’s healthcare fraud prevention and enforcement efforts recovered $4.2 billion in taxpayer dollars in FY2012. The number is the highest annual amount recovered so far and factors into the three-year average ROI of $7.90 for every $1.00 spent. Efforts to crack down on fraud, waste, and abuse in Medicaid and Medicare included the use of a new command center to improve fraud detection and investigation, drive innovation, and help reduce improper payments.

The full HCFAC report can be found here.

This Fed Reports Substantial ROI from Healthcare Fraud Prevention Efforts was first published on Medicaid RAC | HMS.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report in January indicating that Medicaid third party liability (TPL) savings have increased since 2001.

Specifically, state efforts have increased cost avoidance and pay-and-chase savings from $34 billion in 2001 to $72 billion in 2011. Many states attributed increased savings to the utilization of electronic systems for data matching and verification, as well as to assistance from contractors who specialize in TPL. Additionally, the OIG also reported that 44 states indicated that $4 billion are at risk, mainly in the health insurance arena, and offered the following recommendations to CMS:

1. Work with states to address longstanding challenges related to identification of insurance coverage and recovery of payments;
2. Address states’ challenges with one-year timely filing limits for Medicare and TRICARE; and
3. Work to strengthen enforcement mechanisms designed to deal with uncooperative third parties.

The full OIG report can be found here.

This OIG Discusses Medicaid Savings and Recommendations was first published on Medicaid RAC | HMS.

Members of the National Governors Association spoke recently about broad policy changes facing states in 2013 — including healthcare. Some governors are hoping the federal government will be flexible and allow states to submit their own innovative solutions to healthcare reform implementation. Others acknowledged that a one-size-fits-all approach would not be appropriate and encouraged states to keep their citizens’ needs in mind when developing a healthcare reform solution.

Click here to read more about the governors’ remarks.

This Governors Discuss Healthcare Challenges Facing States in 2013 was first published on Medicaid RAC | HMS.

Section 6411 of the Affordable Care Act (ACA) requires states to partner with Medicaid Recovery Audit Contractors (RACs) to identify overpayments and underpayments by the state Medicaid agency; recoup overpayments; create processes for appealing adverse determinations; and coordinate recovery efforts with other entities.

As of November, 34 states have awarded Medicaid RAC contracts and 11 states have converted existing contracts. However, several of these states have been slow to start their Medicaid RAC initiatives for a variety of reasons. A number of states were waiting for the Supreme Court to rule on the ACA and/or on the outcome of the presidential election before moving forward with a robust Medicaid RAC implementation. Other states have been grappling with the technical considerations: for a Medicaid RAC program to be truly effective, vendors should be provided with very detailed paid claim data extracts. The additional programming and IT resources needed from both MMIS and Medicaid Data Warehouse vendors have been challenging for states to manage.

Unfortunately, postponing the Medicaid RAC implementation for any reason can have a negative impact on states and other Medicaid stakeholders, including:

• Delayed recovery revenue for the Medicaid program
• Lost recovery opportunities for claims that age out of the Medicaid RAC review period
• Provider confusion when communicated timeframes for releasing scenarios and reviews are not met

Therefore, it is of the utmost importance that states begin their Medicaid RAC initiatives as quickly as possible. To get their Medicaid RAC programs up and running smoothly and effectively, states should consider these best practices:

• Prepare as early in advance as possible for the data transfer needed to support the Medicaid RAC agenda.
• Offer proactive, educational outreach to the provider community. Educational opportunities include identifying the Medicaid RAC contractor, communicating RAC review/audit procedures, and presenting guidelines for provider responses.
• Ensure that responsibilities for claim selection, overpayment identification, provider outreach, and recovery are clearly defined among the state agency, MMIS vendor, and Medicaid RAC vendor(s) to avoid confusion and potential stakeholder abrasion.
• Support program efficiency and transparency for providers by using a robust provider portal and enabling electronic transmission of medical records.

Additionally, if a growing portion of Medicaid spending is under the managed care umbrella in a state, encounter data can be incorporated into the Medicaid RAC scope in an effort to ensure that no improper payments are going undetected.

With these strategies in place, states should begin seeing recoveries within 6-12 months of starting their Medicaid RAC program, and achieve full recovery streams within 12-15 months.

This Tips for Effectively Beginning a Medicaid RAC Program was first published on Medicaid RAC | HMS.

The Centers for Medicare and Medicaid Services (CMS) has released guidance that indicates that states cannot expand their Medicaid programs to less than 133% of the federal poverty level (FPL) and still receive 100% federal matching funds that are available from 2014 through 2016. If states decline to expand coverage to 133% FPL but would like to propose demonstrations that include a partial expansion, CMS will consider them. However, they would be subject to the regular Medicaid federal matching rate.

In 2017, when the 100% match is reduced, CMS says that it will consider section 1115 Medicaid demonstrations with the enhanced federal matching rates in the context of overall system demonstrations.

The FAQ sheet that clarifies CMS’ stance on this issue and others can be found here.

This CMS Releases Guidance on Federal Funding for Partial Medicaid Expansion was first published on Medicaid RAC | HMS.