RAC Audits On Hold, Pressure For Permanent Changes
By Christine Kern, contributing writer
Facing huge backlog in appeals, CMS temporarily pauses RAC audits
Begun in 2009, the Recovery Audit Program (RAC) was designed to review claims to detect and correct inappropriate Medicare payments. Presently, Modern Healthcare reports CMS is effectively suspending the program with its current contractors while it awards new contracts. Beleaguered by backlogs and delays, RAC has been under attack from many sides. The temporary suspension could be seen as tacit acknowledgment of the need to address issues with the program, according to some healthcare analysts.
According to the CMS memo announcing the program’s suspension, there are several key dates providers should note:
• February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)
• February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration
• June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustments
McKnight’s reports this means “effectively halting all auditing,” according to the American Coalition for Healthcare Claims Integrity, an association representing the auditors.
Understandably, the auditors' group blasted the pause, arguing that the RAC program recovers more than $1 billion in improper payments each quarter. The association stated hospitals seeking less oversight and a “complicit” Congress have joined forces to undermine the program, which will hurt taxpayers and Medicare's solvency.
Other groups are supportive of the hiatus and hope that it foreshadows permanent changes in the program. “I'm interpreting this as the CMS using the pretext of re-procurement as a reason to pause the program and address the enormous amount of concern that has arisen from the provider community,” said Emily Evans, a partner and legislative/regulatory analyst at Obsidian Research Group. “I expect this hiatus to be prolonged; I don't think this is a couple month's thing or a six-month thing.”
According to Mark Parkinson, CEO and president of the American Health Care Association/National Center for Assisted Living, the pause is a "welcomed next step" as long-term and post-acute care providers continue to press for "timely and appropriate initial Medicare claim processing and early appeal decisions.”
The temporary hiatus is seen as necessary since the appeals process has become so overloaded that HHS' Office of Medicare Hearings and Appeals recently began notifying hospitals that it won't be able to accept new appeals until the system is caught up.
The pressure is growing as the 65 administrative law judges in place were expected to see 2,000 claims per week, not the 15,000 weekly submissions they currently receive. As a result, there is a backlog of some 350,000 appeals.