Medicare Part A and Part B providers and suppliers appealing Medicare audit decisions at the administrative law judge (“ALJ”) level or through a judicial review must meet an amount in controversy (“AIC”) threshold amount pursuant to regulation at 42 CFR 405.1006(b) and (c). The regulations require the Secretary of the…
As many already know, when a review contractor (e.g., Recovery Audit Contractors (“RACs”), Medicare Administrative Contractors (“MACs”), the Comprehensive Error Rate Testing (“CERT”) contractor, the Program Error Rate Measurement (“PERM”) contractor, and Zone Program Integrity Contractors (“ZPIC”)) identifies an improper payment, the review contractor requests medical documentation from the provider…
Section 6411 of the Patient Protection and Affordable Care Act (“PPACA”) requires states to establish a Medicaid recovery audit contractor (“Medicaid RAC”) program similar to the existing Medicare RAC program. Like Medicare RACs, Medicaid RACs will be tasked with auditing claims to identify overpayments and underpayments and will be compensated…
This month, the Centers for Medicare and Medicaid Services (“CMS”) published a revised recovery audit contractor (“RAC” or “Auditors”) statement of work (“SOW”) which is, as CMS described, a “contract” between CMS and the Auditors to support CMS in its mission to “reduce Medicare improper payments through the efficient detection…
The Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) has issued its monthly Recovery Act Oversight report for July 2011. The report revealed what many already know: audits and investigations are have increased considerably since 2009, the year the American Recovery and Reinvestment Act of 2009…
On July 28, 2011, the House Oversight and Government Reform Committee held a hearing on Improper Medicare Payments. The hearing highlights the ongoing friction between providers and recovery audit contractors (RACs) and the fact that the Centers for Medicare and Medicaid Services (CMS) is continuing their effort to combat fraud…
The Centers for Medicare & Medicaid Services (“CMS”) recently released the Medicare Fee-For-Service Recovery Audit Program (“RAC”) statistics for the third quarter of the fiscal year (“FY”) 2011. $233.4 million of overpayments was collected during that time period. In comparison, only $55.9 million of underpayments was returned during the same…
On June 30, 2011, the Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule which eliminates the requirement that physicians and non-physician practitioners must sign requisition forms for clinical diagnostic laboratory tests. The original policy was established by the final 2011 Medicare Physician Fee Schedule, but it was…
On June 23, 2011, the Departments of Justice and Health and Human Services announced that, under the aegis of the inter-agency Health Care Fraud Prevention and Enforcement Action Team (HEAT) program, three employees of the Solstice Wellness Center, a Brooklyn-area clinic that purported to specialize in providing physical therapy and…
By correcting vulnerabilities identified by Recovery Audit Contractors (“RACs”) and similar Medicare contractors, the Centers for Medicare and Medicaid Services (“CMS”) hopes to reduce the rate of mistakes uncovered by the Comprehensive Error Rate Testing (“CERT”) program. Diagnosis Related Group (“DRG”) Validation review is one of the processes RACs utilize…