The Medicaid Recovery Audit Contractor (RAC) final rule includes many of the
recommendations that the American Medical Association (AMA), Pennsylvania Medical Society (PAMED), and nearly 80 other state and specialty societies submitted in response to the proposed rule.
The rule, which implements Section 6411 of the Patient Protection and Affordable Care Act effective Jan. 1, 2012, means that physicians will have one more potential audit to worry about.
Issued by the Centers for Medicare and Medicaid Services on Sept. 14, 2011, the final rule is intended to provide guidance to states related to federal and
state start-up funding, operation and maintenance costs of Medicaid
RACs, and the payment methodology for state payments to Medicaid RACs.
The final rule includes a three-year claims look-back period. States must set limits on the number and frequency of medical record requests, adequately incentivize the identification of underpayments, and coordinate the efforts of the RACs with other auditing entities.
According to the final rule, RACs must
- Employ a full-time physician medical director
- Hire certified coders
- Provide outreach and notify providers of audit policies and protocols
- Accept submission of electronic medical records by fax, CD, or DVD
- Return the contingency fee if an overpayment determination is reversed at any level of appeal
It also stipulates that RACs cannot audit claims that have already been audited or are currently being audited by another entity.