Updated on: January 30, 2013

Medicaid RAC Expects ‘Revenues to Increase’ from Recoveries in Q3 and Q4

Original story posted on: August 14, 2011









The Medicaid Recovery Audit Contractors (RACs) could be gearing up to hit providers if one contractor’s quarterly report is any indication.

PRG Schultz International’s quarterly report for the quarter that ended June 30 noted it was awarded Mississippi’s Medicaid RAC contract and stated that it will “evaluate and bid for additional Medicaid RAC opportunities.” It also states that “while the magnitude and timing of additional health care claims recovery audit revenues are difficult to predict, we expect those revenues to increase in the third and fourth quarters of 2011 compared to the first half of the year.”


Other Medicaid RACs are less direct but also show an expectation of revenue in the coming months and 2012. HMS, which is the Medicaid RAC or subcontractor for at least seven states including New York and Tennessee, expects “a very promising pipeline for 2012,” said CEO Bill Lucia in a statement about the company’s second-quarter report.

Two Medicare RAC issues posted

On the Medicare side, RAC regions B and D saw new issues posted recently. They are:

Part B

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Mohs surgery with pathology billed by separate provider J2


Alaska, Ore., Wash.

If the preparation and interpretation of the slides of tissue taken during the Mohs surgery are performed by someone other than the surgeon or his or her employee, then Mohs surgery may not be billed.

LCD L23735 effective with date of services performed on or after April 1, 2008


Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

SNF consolidated billing


RAC Region B

Services are being billed separately that should be included in the skilled nursing facility (SNF) consolidated billing. Consolidated billing is when services provided during the resident's stay in a SNF are bundled into one package and billed by the SNF. Under the consolidated billing requirement, a SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services).

CMS Pub 100-04

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.

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Karen Long

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