Breaking News 2013
MEDICAID RAC AUDITS
The State of Alaska Medicaid RAC contract was signed in May 2012 and awarded to HMS. The contract is a multi-state joint contract with Alaska, Idaho, Montana, and Utah.
HMS data analysis extends to all provider types, including hospital inpatient and outpatient, pharmacy, dental, long term care, hospice, and behavioral health. HMS will be paid on a contingency basis. Although HDI will perform Medicaid RAC audits in Alaska, Myer’s & Stauffer will continue with their current Medicaid billing audits.
DRG Billing & Coding Issues
Quality of Care
Coding and Clinical Review Patterns
Overpayment Review (overpayments must be returned in 60 days)
Immediate Focus on High Expenditure Providers (hospitals)
Individual Services versus Bundled Services
- Potential overpayments are identified through a comparative analysis of facility records and Medicaid Assistance claims payment history and eligibility. A comprehensive review is performed to identify all dual-eligible Medicaid recipients.
- In conjunction with all types of healthcare providers, HMS intends to perform separate Medicaid RAC Audits on all long term care facilities.
Review financials for ALL Medicaid eligible residents in facility.
Initial review period is 2-1/2 years with a six month look back since inception.
“Rural hospitals are at risk,” NRHA senior national vice president Brock Slabach told RAC monitor, “the entire rural (hospital) infrastructure is beginning to deteriorate….
CMS published the Final Rule expanding the Federal Recovery Audit Contractor program to state Medicaid agencies. The regulations were effective starting January 1, 2012.
The State of Washington Medicaid Rac Contract was signed in May 2012. CGI will conduct audits and support the work of the Health Care authority staff in compliance with the Final Rule Regulations.
The State of Washington has recently signed a contract with CGI to perform the Medicaid RAC audits. CMS announced that CGI will begin the Medicaid RAC Audits in the State of Washington on October 1st, 2012. CGI intends to start their Medicaid RAC audits with the Critical Access Hospitals. Listed below are some of the significant highlights that will be addressed on the audits:
- High focus for critical access hospitals inpatient claims include:
- Short stay /observation
- High dollar claims
- Medical necessity
- Correct coding specific to Washington Medicaid codes
- The Rac auditors will perform both desk audits and site review audits.
- Providers must send in records within 30 days of request. CGI must respond with preliminary findings within 60 days.
- CMS encourages providers to update their contact information.
- Provider Assistance and Online tools will be provided, including an HCA/Washington RAC Online Portal.
- Provider can also access and review their audit finding status by going to http://wahca.cgicleve.com.
- CGI auditors have selected July 2010 as the claims look back period.
- Providers may request an exit conference where CGI will provide summary level findings.
- CGI will issue the following letters: medical records request, preliminary review results, final review notice, and informal dispute response letter.
- One of the new target areas outlined in OIG 2013 work plan is critical access hospital’s payments for swing bed and long term care services.
- Providers can appeal within 28 days from the date of the final review results.
Articles & Links
Articles published in Washington Healthcare News
- July, 2010: 15.6 Billion Returned to the Medicare Trust Fund From All Fraud Audit Recoveries Since Inception in 1997
- September, 2008: Recovery Audit Contractors Are Not Going Away...Will Your Facility Survive the Assault?
- December, 2008: OIG Holds Hospital Boards Accountable on Fraud Audits
- March, 2009: Boost Your Critical Access Hospital Bottom Line Swing Bed Designation
- September, 2009: How Benchmarking Can Help Your Facility Achieve Financial Wellness
- March, 2010: Government Budget Deficits Triggering Increased Provider Audits
FCAW's Most Recent Newsletter
- Summer 2012 Articles Include:
- CMS posts year-end improper payment figures
- CMS posts Q4 improper payment figures
- Highest Error Rate by Programs
- Some Error Rates Decline
- From the Field: Demand Letter Confusion
- CMS considers edits correct common Overpayments
- Further edits listed transmittal R1031OTN,
- MAC auditors begin road show – Focus Short Stay
- ZPICs Dive Deep to Identify Fraud, Demands are Questioned
- Many Roads Lead to Investigations
- Medicaid RAC expected to recover more than MICs
- RAC Letters Shifted to MACs Bid to Solve lateness Problems
- SNF Billing Intense Rehab Review
- Prepayment Review: New Kids on the Block
- Error Rates High, RAC Prepayment Demo Returns
- HealthDataInsights post two New issues, Medical Necessity
- New CMS Policy Three-Day Payment Window Physician Final Rule
- Some Readmissions Will be Costly
- CMS: Physician Role Medical Necessity Denials
- Rural Health Clinic & Federally Qualified Health Clinics
- Hospice Home Health Agency (“HHS”) Providers Subject to RAC Audits
- Audit Risk Home Health Agencies: Face to Face Certification Requirements
- OIG to Ramp Up Compliance Reviews, Develop Best Practices Provider Must re-enroll with Medicare by 3/2013
- If initially enrolled prior to 3/2011
- Critical Access Hospitals (CAHs) are different at least for Medicare
- The RAC Investigate CAHs?
- How Are CAHs Different?
- Previous FCAW newsletters available upon request
CMS Post top recovery Audit
MAC – ZPIC Issues
Which Auditor will head Medicaid RAC recovery
RAC Letters Shifted to MAC prepayment
SNF Billing Issues
Health Data Insights
Physician Point Service Encounters
Rural Health Clinic
Hospice - Homecare Agencies
CAH – Issues
- Long Term Care Corporate Integrity Agreements
- OIG Semiannual Report to Congress
- Critical Access Hospital Regulation Update
- MedPAC releases comments to CMS on reform
- MedPAC June 2009 Report to Congress
Federal Government Links
- HHS Medicare
- U.S. Government official web portal
- HHS Office of Inspector General
- HHS Skilled Nursing Facility Center
- 2010 MLN Matters Articles
- HHS CERT overview
- Code of Federal Regulations (CFR)
State of Alaska Medicaid
- Alaska Health Care Services
- Alaska Medicaid State Plan
- Alaska Medicaid- Alaska Medical Assistance
- Medicaid Rate Advisory Commission
- Alaska Statutes
State of Washington
- Department of Social & Health Services
- State of Washington Aging & Disability Services Administration