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Connie Leonard, Director, Division of Recovery Audit Operations Melanie Combs-Dyer, CMS RAC Senior Technical Advisor Medicare Recovery Audit Contractors.

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Presentation on theme: "Connie Leonard, Director, Division of Recovery Audit Operations Melanie Combs-Dyer, CMS RAC Senior Technical Advisor Medicare Recovery Audit Contractors."— Presentation transcript:

1 Connie Leonard, Director, Division of Recovery Audit Operations Melanie Combs-Dyer, CMS RAC Senior Technical Advisor Medicare Recovery Audit Contractors (RACs) 1

2 Background: IPIA Improper Payment Information Act requires federal agencies to measure improper payment rates “Improper payments” include overpayments underpayments 2

3 RAC Legislation Medicare Modernization Act Section 306: required RAC demonstration Tax Relief Act and Healthcare of 2006, Section 302: requires permanent and nationwide RAC program by no later than 2010 Both statutes gave CMS the authority to pay RACs on a contingency fee basis. 3

4 RAC Program Mission… to detect and correct past improper payments, to implement actions that will prevent future improper payments. Providers can avoid submitting claims that don’t comply with Medicare rules CMS can lower its error rate Taxpayers & future Medicare beneficiaries are protected 4

5 Results of the RAC Demonstration Collections exceeded costs Overpayments Collected: $992.7 m Less Underpayments Repaid:-($37.8 m) Less $ Overturned on Appeal: Less PRG IRF Re-review: - ($46.0 m) ($14.0 m) Less Costs to Run Demo:-($201.3 m) BACK TO TRUST FUNDS $693.6 m 3/27/05-3/27/08 (Claim RACs & MSP RACs) 5 Report now available at

6 Results of the RAC Demonstration Appeals were minimal 6 Cumulative through 3/27/2008 Number of Claims with Overpayment Collections Claims Appealed By Provider to Any Level Appealed Claims with Decision in Provider's Favor Percentage of Overpayment Determinations Overturned on Appeal NumberPercentNumberPercent All Claim RACs 442,91551, % 20, % 4.6%

7 Results of the RAC Demonstration RACs affected a very small percentage of all Medicare Payments $316 billion Medicare Payments Unaffected by RACs 99.7% $1.0 billion Medicare Payments corrected by the RACs 0.3% 3/27/05-3/27/08 (Claim RACs & MSP RACs) 7

8 Results of the RAC Demonstration Most overpayments were collected from inpatient hospitals SOURCE: RAC Data Warehouse 6% IRF, $59.7m 2% Skilled Nursing, $16.3m 4% Outpt. Hospital, $44.0m 1% Durable Med Equip, $6.3m 2% Physician, $19.9m <1% Ambulance/Lab/Other, $5.4m 85% Inpatient Hospital, $828.3 m 8

9 Change: Limit the number of medical record requests Limit the RAC “look-back period” Concern: RACs had a significant financial impact on some providers Lessons Learned 9 Concern: RACs were not required to hire physicians and certified coders Change: CMS has required each RAC to hire a physician medical director CMS has required each RAC to hire certified coders Concern: Some providers questioned the accuracy of RAC reviews Change: New issue review board (greater oversight) Independent validation contractor Annual accuracy rates for each RAC Concern: The RAC program was not transparent enough Change: New issues posted to web Vulnerabilities posted to web RAC claim status website

10 D C B A RAC Expansion Schedule Oct. 1, 2008 March 1, 2009 Aug. 1, 2009 or later

11 Key Website & Contact Information 11

12 Provider Feedback Questions How would you (providers) like to learn about the Recovery Audit Contractor program? What is the best vehicle for reaching and providing outreach to providers? How would you (providers) like to learn about vulnerabilities identified by a Recovery Audit Contractor? What format will help you in your practice or facility? (These are vulnerabilities that have been identified in a large scale. These are not specific findings for a single facility. Specific findings will be communicated through written correspondence.) All Recovery Audit Contractors will develop a web-based tracking system to allow providers to track claims requested by a RAC. What information should the RACs include in this system? Please keep in mind that Personal Health Information (PHI) cannot be included.


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