The Council for Medicare Integrity, which represents Recovery Auditors, is asking HHS Secretary Alex Azar to let RACs audit more claims and to push Congress for a permanent RAC prepayment review program. The RACs say the audits “have absolutely no direct impact on the Medicare providers” but past provider complaints about audits led to program reforms.
In a March 6 letter to Azar, the council asks his “support of the Medicare integrity programs put in place by Congress to prevent Medicare waste and request those efforts be increased to dramatically reduce the billions lost each year to improper payments.”
Fee-for-service Medicare had an improper pay rate of 9.5 percent in fiscal 2017, and is considered a high-priority program, according to the federal government’s payment accuracy website.
Allowing prepay reviews and reviews of additional claims “could go a long way toward improved solvency,” the RACs say. The council also says these are private sector best practices.
The council notes that RACs have gone from reviewing more than 800 claim types to fewer than 30, and the additional document review limits have been set so that the auditors can look at only 0.5 percent of a provider’s claims. The RACs say providers that bill Medicare comply without issue with more extensive claim review requirements from private payers, and that is considered a basic cost of doing business. With Medicare, though, the council says providers have “lobbied aggressively to keep their overpayments,” and pressured CMS to block oversight.
The council is asking HHS to allow RACs to review 5 percent of claims. The group also says that in the longer term, it would welcome a discussion about risk-based document review limits.
CMS says in fact sheet on document reviews that 0.5 percent is the baseline annual document review limit for institutional providers. CMS’ website says the agency began establishing document review limits based on provider compliance in Jan. 2016 as one of many changes made to the program in response to provider complaints. The American Hospital Association has suggested more changes to the RAC program as part of its lawsuit over the backlog of Medicare appeals.
A spokesperson for the council says that CMS technically has the authority to institute risk-based document review limits, but the agency hasn’t fully implemented them yet. She added that while the council agrees in principle with the risk-based document review limitations, the proposed scale is unacceptable.
“First, a review of .5% does not allow for any statistical validity. The current paradigm determines a provider’s error rate by reviewing only .5% of their claims. Second, within this current sliding scale ADR limit paradigm, providers who demonstrate a 95% error rate will only be subjected to a maximum of 5% ADRs. We feel that any provider that has an error rate that high should warrant a more comprehensive audit,” the spokesperson said in an email.
The council also says in the letter it wants to expand the types of claims that can be reviewed for billing errors, as well. One provider lobbyist said that with the letter to Azar, the RACs appear to be trying to expand their business.
The council also says CMS should consider making the audit scenario review process more efficient and expediting audit processes that have previously approved. The auditors say this should be similar to the discussion around making Medicaid waivers more efficient.
RACs are also pushing for CMS to ask lawmakers for a permanent prepay review program, as they say the prepay review demonstration was successful.
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