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Program focuses on recovering payments for Medicare
The recovery audit contractor program has been expanded to all states, and CMS is working to resolve physicians’ complaints.
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Ocular Surgery News is pleased to announce the addition of a new column that will appear periodically in our Regulatory/Legislative Section, entitled “Insight into CMS.”
The column will be authored by William D. Rogers, MD, FACEP, a physician who serves as the Medical Officer to the Office of the Administrator of Centers for Medicare and Medicaid Services and as the Director of the Physicians Regulatory Issues Team at CMS, an initiative designed to reduce the regulatory burdens on physicians and other health care providers.
In addition to his duties at CMS, Dr. Rogers maintains a clinical practice in emergency medicine.
He will write on legislative and regulatory initiatives at CMS from the perspective of the physician.
While he anticipates identifying topics that he believes are of interest to physicians, he welcomes comments and questions from our readers and, where appropriate, will try to respond through his column.
Alan E. Reider, JD
OSN Regulatory/Legislative Section Editor
On Dec. 8, 2003, President Bush signed the Medicare Modernization Act, which changed the Medicare program profoundly. Prescription drug coverage was mandated, several new preventative services were added, and payment for drugs administered in the office was dramatically altered. The bill was 678 pages, and among the less noticed provisions was Section 306.
Section 306 of the Medicare Modernization Act says in part: “The Secretary shall conduct a demonstration project under this section to demonstrate the use of recovery audit contractors under the Medicare Integrity Program in identifying underpayments and overpayments and recouping overpayments under the Medicare program for services for which payment is made under part A or B of title XVIII of the Social Security Act.”
Recovery audit contractor
 William D. Rogers |
The concept of a recovery audit contractor (RAC) is a new one because the act also specified that “payment may be made to such a contractor on a contingent basis.” In effect, the audit contractors would be paid on the basis of the amount of Medicare payments that they recovered through audits of charges submitted. The act further specified that the contractors needed to have “the appropriate clinical knowledge of and experience with the payment rules.”
In March 2005, the RACs were announced. The contractors began by examining part A claims. They did not begin to examine physician claims until October 2005.
In November 2006, the CMS released a RAC status report, which found that the RAC process had recovered $54.1 million for the Medicare trust fund and that another $232 million had not yet been collected but had been identified as overpayments. The report also showed that $2.5 million was identified for payment to providers who had been underpaid.
In December 2006, Congress passed the Tax Relief and Health Care Act, Section 302, which expanded the RAC program to include all 50 states and made it a permanent program.
Problems with contractors
Since the implementation of the three-state demonstration, the Physicians Regulatory Issues Team has heard from a number of physicians who were having problems with the RACs in their state. The problems have ranged from requests for patient records that were more than 4 years old (a system fix was required) to requests for an impractical number of records.
We have worked with the RACs to fix the complaints and have found them to be proactive once they learned of a complaint. The CMS staff who manage the RAC contracts have been helpful in resolving physician issues, and the complaints have helped them write a request for proposal for the RAC expansion, which ensures that the new RACs will be more “physician friendly.” The draft proposal, for instance, requires that the RACs employ a medial doctor or a doctor of osteopathy as a contractor medical director. We all know how we depend on our local carrier medical directors. Having a doctor in a similar role with RAC will be of inestimable help. Look for an announcement of another major initiative that will further reduce unnecessary audits and demands.
The recovery audit contractor concept is here to stay. As a taxpayer, I appreciate the goal of recovering inappropriate Medicare payments. As a physician, I worry about the potential burden the RACs might pose for physicians, from copying reams of patient records to appealing claims when they seem to be wrong about an overpayment. We at CMS are aware of these potential problems, and we will work with you and the RACs to ensure that their audits are reasonable and their decisions are well informed. If you are having problems with a recovery audit contractor, we would like to hear from you. You can e-mail us at PRIT@cms.hhs.gov.
For more information:
- William D. Rogers, MD, FACEP, can be reached at the Office of the Administrator, CMS/HHS, Room 314-G, 200 Independence Ave. SW, Washington, D.C. 20201; 202-690-5907; e-mail: william.rogers@cms.hhs.gov.