The Patient Protection and Affordable Care Act (aka the health care reform bill currently under consideration by the Senate) has implications for the RACs. Of most relevance in this 2074 page bill is Section 6411 which seeks to expand RACs to Medicare Parts C and D by 12/31/2010. The RAC program would also be expanded to Medicaid. The Medicaid RACs, like the current RACs, would be charged with identifying and recovering overpayments and would be paid on a contingency basis. States will be required to contract with one or more RACs to identify overpayments. States will also need to have an adequate appeals process in place for providers to contest overpayment determinations. Given the complexity of Medicaid and the variations from State to State, this is likely to be quite a mess. It is not certain whether this bill will pass in the Senate nor how it might be amended. Nevertheless, the fact that the government is seeing to expand the reach of the RAC program even before the current RACs are up to speed indicates the confidence the government has in the likely effectiveness of the program.
CMS recently issued a transmittal with instructions to Zone Program Integrity Contractors (ZPIC) – new Medicare contractors who are replacing the Program Safeguard Contractors (PSCs) – regarding suppressions and exclusions in the RAC Data Warehouse. The RAC Data Warehouse is a web-based application that enables the RACs to determine if another entity already has a specific provider or claim under review. The goal is to prevent conflicts between RAC activity and the the activities of other Medicare contractors. The recent transmittal specifically requires ZPICs to enter suppressions in the RAC Data Warehouse to mark providers or subsets of a provider’s claims as off-limits to the RACs and unavailable for RAC scrutiny. Given the increased scrutiny all providers are experiencing, hopefully the RAC Data Warehouse will function as intended and spare a provider from having the same claim(s) reviewed by RACs, MACs, ZPICs, QIOs etc etc.
As if further evidence was needed that fighting Medicare fraud is on the front burner in Washington, Senator Chuck Grassley (R-Iowa) recently introduced a bill called Fighting Medicare Payment Fraud Act of 2009. This bill would allow HHS up to extend the amount of time before paying claims from the current 30 days (prompt payment rule) to up to one year if there is a suspicion of potential fraud or abuse. This would allow CMS more time to review claims before payment is made. The bill would authorize this extension for certain suspect categories of providers or specific providers. The bill would also require the Office of Inspector General (OIG) to provide annual recommendations of categories of providers or suppliers where additional scrutiny is needed before payments are made under the prompt payment rule. Click here to read the Senator’s thinking behind this new bill.
The four RACs are continuing to post new approved issues on their websites and expanding their reach. Hospice remains, thankfully, off their radar screen. Long may that last… !
