CMS RAC­ing up re­cov­er­ies

85% over­turned in fa­vor of providers, AHA says

Modern Healthcare - - Front Page - Jessica Zig­mond

The Amer­i­can Hos­pi­tal As­so­ci­a­tion said last week that it is pleased the CMS has re­leased data on what it has re­couped in im­proper Medi­care pay­ments, but would still like to see in­for­ma­tion about the ap­peals process in the agency’s re­cov­ery au­dit con­trac­tor pro­gram.

On April 26, the CMS is­sued the first of what it ex­pects will be quar­terly re­ports on the Medi­care fee-for-ser­vice re­cov­ery au­dit pro­gram since it be­came a per­ma­nent na­tional pro­gram last year. De­signed to weed out fraud and abuse, the RAC pro­gram re­lies on four con­trac­tors—Di­ver­si­fied Col­lec­tion Ser­vices, CGI Inc., Con­nolly Inc. and HealthDataIn­sights—to iden­tify im­proper pay­ments on claims to Medi­care ben­e­fi­cia­ries in four geo­graphic re­gions of the coun­try.

The re­port last week showed that from Oc­to­ber 2009 un­til March 2011, the pro­gram had iden­ti­fied and re­couped a to­tal of $313.2 mil­lion in im­proper pay­ments, with more than half of that amount— $162 mil­lion—col­lected in the first quar­ter of this year alone. This amount rep­re­sents pay­ments from all providers, not only hos­pi­tals, ac­cord­ing to the CMS. Com­mon is­sues for over­pay­ments in­cluded im­proper cod­ing and billing for bun­dled ser­vices sep­a­rately.

Mean­while, about $52.6 mil­lion in un­der­pay­ments were re­turned to providers in that pe­riod, in­clud­ing $22.6 mil­lion be­tween Jan­uary and March of this year. Some providers, how­ever, have yet to re­ceive those funds.

El­iz­a­beth Bas­kett, se­nior as­so­ciate di­rec­tor for pol­icy at the AHA, said the as­so­ci­a­tion mon­i­tors this and other is­sues re­lated to the RAC pro­gram in AHA’s RACTRAC, an on­line tool that pro­vides in­for­ma­tion and sur­veys hos­pi­tal mem­bers about the pro­gram.

“In that process, they share is­sues and a com­mon concern that has been raised is that

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