Recovery Auditing Is Vital To Medicare Solvency
Medicare loses more money to waste than any other federal program government-wide and is slated to be insolvent by 2028. As a result of the program’s consistent ranking on the GAO “High Risk List”, in 2006, Congress mandated the creation of a Medicare oversight program to ensure that providers are fairly reimbursed by Medicare and the solvency of the Medicare Trust Fund is maintained. Following a highly successful three-year pilot program, the Centers for Medicare and Medicaid Services (CMS) launched the national Recovery Audit Contractor (RAC) program nationwide in 2009 to review post-payment Medicare claims, identify billing errors and ultimately, return Medicare overpayments back to the Trust Fund and underpayments to providers.
Recovery audit contractors evaluate a wide variety of areas with high Medicare billing error rates and CMS then approves the particular areas with improper payment issues that the auditors are then authorized to review. Recovery Auditors currently review just 0.5% of a provider’s Medicare claims to ensure that their billing complies with Medicare policy.
The goals of the RAC program include:
- Detecting and correcting past improper payments so CMS may implement actions to prevent future improper Medicare payments
- Identifying areas of provider confusion within Medicare billing
- Assisting CMS in addressing the high error rate within Medicare – currently 11% which equates to a loss of $41 billion per year
- Helping to maintain the future solvency of the Medicare Trust Fund for the millions of seniors who rely on the program
As a condition of the permanent Recovery Audit Contractor program, Congress has required the contractors be paid by contingency fee, withholding a portion of their recoveries to ensure a high-level of precision in identifying true billing errors only.
Key Accomplishments Of The Program
- More than $10 billion in overpayments have been returned back to the Medicare Trust Fund
- More than $800 million in underpayments have been returned to providers
- Recovery auditors have consistent maintained an accuracy rate of more than 95% as determined by a third party reviewer (the RVC)
- The majority of RAC decisions are upheld on appeal – only 9.3% of RAC findings are overturned on appeal
- RACs have uncovered confusion among providers related to whether patients should be admitted as inpatient or outpatient, leading to important changes in Medicare policy
- Named ‘Most Improved’ healthcare integrity program in terms of dollars returned to the government by the OIG in May 2014
On October 31, 2016, the Centers for Medicare and Medicaid Services (CMS) awarded the second round of contracts for the Medicare Fee-for-Service’s (FFS) Recovery Audit Contractor (RAC) Program, extending the vital program that identifies and returns Medicare improper payments back to the Trust Funds.
Five new contracts have been awarded – four regional contracts and one for a new region focused solely on auditing DME/HH-H claims nationwide. RACs in Regions 1-4 will conduct post-payment reviews to identify improper payments made in Parts A and B, excluding Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DME- POS) and Home Health/Hospice (HH-H) providers. The RAC in the newest region, Region 5, will conduct post-payment reviews on DMEPOS and HH-H nationwide.
- Support the work of Recovery Auditors to ensure providers are fairly reimbursed
- Continue ongoing dialogue among Medicare stakeholders to improve the Recovery Audit program
- Increase provider education and support to bolster compliance in billing within Medicare policy
- As recommended by the OIG, increase training of ALJs so their determinations are consistent with Medicare policy
- Maintain robust, consistent oversight of Medicare billing to maintain the solvency of the Trust Fund for future beneficiaries