What Type of Reviews Are Performed by Fis and Macs?
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Medicare Fee-for-Service Compliance Programs: Medicare Fee for Service Recovery Audit Program
Guidance for The Medicare Fee for Service (FFS) Recovery Audit Program's mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers then that the CMS tin can implement actions that volition prevent future improper payments in all fifty states.
Practise yous take questions or concerns nigh the Recovery Audit Program? Please electronic mail us at RAC@cms.hhs.gov. Please Practise Not transport Personal Health Information to this e-mail accost.
The Medicare Fee for Service (FFS) Recovery Audit Program'south mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments fabricated on claims of wellness care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS tin can implement deportment that will prevent future improper payments in all 50 states.
What does a Recovery Inspect Contractor (RAC) exercise?
RAC'due south review claims on a post-payment basis. The RAC'southward detect and right past improper payments so that CMS and Carriers, FIs, and MACs tin can implement actions that will preclude future improper payments.
Who are Recovery Audit Contractors?
| Region | States | Websites | Phone Number | |
|---|---|---|---|---|
| Region i Performant Recovery, Inc. | CT, IN, KY, MA, ME, MI, NH, NY, OH, RI, and VT | https://performantrac.com/ PROVIDERPORTAL.aspx | info@Performantrac.com | 1-866-201-0580 |
| Region ii Cotiviti, LLC | AR, CO, IA, IL, KS, LA, MO, MN, MS, NE, NM, OK, TX, and WI | https://Cotiviti.com/RAC | RACInfo@Cotiviti.com | 1-866-360-2507 |
| Region 3 Cotiviti LLC | AL, FL, GA, NC, SC, TN, VA, WV, Puerto Rico and U.S. Virgin Islands | https://www.Cotiviti.com/RAC | RACInfo@Cotiviti.com | i-866-360-2507 |
| Region 4 Cotiviti GOV Services (formerly HMS) | AK, AZ, CA, DC, DE, Howdy, ID, Md, MT, ND, NJ, NV, OR, PA, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas | https://rac4info.cotiviti.com | rac4info@cotiviti.com | Office A: 1-877-350-7992 Role B: 1-877-350-7993 |
| Region 5 DME/HHE/ | Nationwide for DMEPOS/HHA/ Hospice | https://performantrac.com/ PROVIDERPORTAL.aspx | info@Performantrac.com | ane-866-201-0580 |
RACs in Regions one-four will perform mail service payment review to identify and correct Medicare claims specific to Role A and Role B.
Region five RAC volition be dedicated to review of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health / Hospice
What Topics do RAC'south Review?
Stay in the know on proposed and approved topics that RAC's are able to review. These topics will be updated monthly on the RAC reviews topic page and include:
- Name of the Review Topic
- Description of what is beingness reviewed
- States / MAC regions where reviews will occur
- Review Blazon (complex review / automated review)
- Provider Types
- Affected Codes
- Applicable Policy References
Recent Updates
March 26, 2021, CMS awarded Performant Recovery, Inc., the incumbent, the new RAC Region 1 contract.
April 24, 2019 - CMS oft receives referrals of potential improper payments from the MACs, UPICs, and Federal investigative agencies (east.g., OIG, DOJ). At CMS discretion, CMS may crave the RAC to review claims, based on these referrals. These CMS-Required RAC reviews are conducted exterior of the established ADR limits.
December 21, 2018 - The CMS has posted an updated version of the Institutional-Provider-Facilities-ADR-Limits certificate (/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Programme/Resources). This update changes the ADR "bike" limit, from nada (0) to i (ane), for those providers who, under the previous methodology would have an ADR "cycle" limit of naught (0), even though their "almanac" ADR limit was greater than zero (due east.thou. 1, two, iii, or 4).
May 17, 2018 - We've updated this Medicare Fee for Service Recovery Audit Plan website to include new pages for Approved and Proposed RAC review topics. These lists volition be updated on a monthly basis. All downloadable documents can now be found on our Resources page.
Jan 29, 2018 - An updated version of the Institutional Provider (Facilities) ADR Limit document is available in the Downloads expanse of the Provider Resource webpage. The updated version includes additional information on how Provider Denial Rates are calculated, for Risk-Based, Adapted ADR Limits.
December seven, 2016 - CMS has posted the Fiscal Twelvemonth 2015 Recovery Inspect Programme Report to Congress in the Downloads department of the Recovery Audit Program'due south main folio. CMS has also posted the FY 2015 Recovery Audit Programme Appendices, as a companion to the Report.
November 24, 2017 - An updated document, listing the Recovery Audit Programme Comeback and their respective implementation (effective) dates is now available in the Download area of the Program Reports webpage.
November 9, 2017 - CMS has begun, as of today, to put a list of review topics that have been proposed, only non however canonical, for RACs to review. These topics will be listed, on a monthly basis, on our Provider Resources page along with details nigh the proposed reviews.
HHS is committed to making its websites and documents accessible to the widest possible audition, including individuals with disabilities. We are in the procedure of retroactively making some documents attainable. If you lot need help accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
DISCLAIMER: The contents of this database lack the force and event of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Section may not cite, use, or rely on any guidance that is non posted on the guidance repository, except to establish historical facts.
Source: https://www.hhs.gov/guidance/document/medicare-fee-service-compliance-programs-medicare-fee-service-recovery-audit-program-0
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