September 15, 2011

CMS Finalizes Medicaid RAC Rule

By

k-long

alert-powered-by-decision-health

 
 

 

Along with the federal program, providers have to watch out for state recovery audit contractors (RACs) starting in 2012.

States that fail to implement their Medicaid RAC programs by Jan. 1 could lose federal financial participation (FFP), according to the final rule posted Sept. 14 as reported by MICmonitor. States will determine what contingency fee to pay their Medicaid RACs, though the federal government will not provide payments for fees that exceed the highest contingency rate of the Medicare RACs.

CMS will require Medicaid RACs to be similar to their federal counterparts in several ways, including the following:

  • Hiring at least one full-time medical director who is a doctor of medicine or doctor of osteopathy;
  • Hiring certified coders, unless the state determines they are not required to review Medicaid claims effectively;
  • Educating providers, “including notification to providers of audit policies and protocols;”
  • Requiring RACs to have several customer-service measures;
  • Limiting review to a three-year look-back period; and
  • Establishing a limit on the number and frequency of records the RAC can request.

States, however, have the flexibility to design their own RAC programs relating to medical necessity reviews, extrapolation of audit findings, external validation of the accuracy of RAC findings and types of claims audited, the final rule states.


New RAC postings

Connolly, the recovery auditor (RAC) for Region C, posted two new issues this week.

Outpatient hospital

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of vaccine administration services

 

RAC Region C

Vaccine administration (90471-90472) are required to be billed with revenue code 0771 for all providers except RHC & FQHC. Providers billed CPT(s) 90471-90472 in revenue codes other than 0771 resulting in billing errors.

CMS Pub. 100-04, chapter 18; TrailBlazer Health Enterprises LCD for immunizations L26762

 

Physician

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of J1642 – Heparin, up to 10 units (Hep-Lock, Hep-Flush) – carrier

 

RAC Region C

Claims identified where J1642 (Heparin, up to 10 units [Hep-Lock], [Hep-Flush]) was billed for patients who receive Heparin for therapeutic infusion. The therapeutic infusion of Heparin should be J1644 (Heparin, up to 1,000 units).

CMS 2010 Table of Drugs, CMS website Alpha-Numeric HCPCS

 

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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