05/20/2019

Recent RAC Monitor Articles

This edition includes an articles on......

Recent RAC Monitor articles you may find informative...

Recovery Audits: Improvements to Protect Taxpayer Dollars and Put Patients over Paperwork

The Medicare Fee-For-Service (FFS) Recovery Audit Contractor (RAC) Program is one of many tools CMS uses to prevent and reduce improper payments. RACs identify and correct overpayments made on claims for health care services provided to beneficiaries, identify underpayments, and provide information that allows us to prevent future improper payments. We reduced RAC-related provider burden to an all-time low, as evidenced by the significant decrease in the number of RAC-reviewed claim determinations that are appealed and the corresponding reduction in the appeals backlog.

Examples of key improvements and enhancements:

• Better oversight
• Holding RACs accountable for performance by requiring them to maintain a 95% accuracy score
• Requiring RACs to maintain an overturn rate of less than 10%
• RACs will not receive a contingency fee until after the second level of appeal is exhausted
• Reducing provider burden and appeals
• Making RAC audits more fair to providers
• Changing how we identify who to audit
• Giving providers more time to submit additional documentation before needing to repay a claim
• Increasing program transparency
• Regularly seeking public comment on newly proposed RAC areas for review, before the reviews begin
• Requiring RACs to enhance their provider portals to make it easier to understand the status of claims

For more information visit the Medicare FFS Recovery Audit Program website. See the full text of this
excerpted CMS Blog (issued May 2).

Federal Judge Upholds Successful Challenge of 340B Reimbursement Cuts

By Mark Spivey
HHS ordered back to the drawing board – and told to work quickly. A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal…. READ MORE

Medicare Advantage Plan Denials. Now What?

By Marvin D Mitchell, RN, BSN, MBA 
There are steps providers should take for holding managed care plans accountable. Considerable effort is regularly devoted by healthcare providers to overcome coverage denials through the application of the governing rules, such as they can be leveraged. Following the rules is tough in a world where money talks, bringing us… READ MORE