Recovery audit contractors are hoping a new report on their past success recovering money for Medicare will cause CMS to reverse course on its decision to limit the number of claims they can review.

RAC’s recovered $473.92 million in improper payments in fiscal 2016, according to A REPORT ISSUED MONDAY by CMS. That number is up from $440.69 million in fiscal year 2015.

RAC’s argue that they could recover more money for the Medicare trust fund if their hands were not tied by the agency. Over the last several years, CMS has removed their ability to review inpatient status claims and limited the number of documents RAC’s can request from providers as part of their reviews. Currently providers with a low history of denial rates are required to turn over less documentation compared to those with known to have higher denial rates.

CMS made these changes after industry executives raised concerns that RAC’s are incentivized to deny claims, and that many of their decisions are overturned on appeal. The Council for Medicare Integrity, a RAC trade association is asking Congress to broaden their ability to review all claims before they are paid.

The report comes as the AHA is seeking to further limit the ability for RAC’s to review their claims. The AHA told a federal court this past summer that hospital claims should be reviewed by quality improvement organizations, or QIOs, instead of RAC’s. The suggestion was in response to A REQUEST MADE BY U.S. DISTRICT JUDGE JAMES BOASBERG on how the Medicare appeals backlog could be reduced.

Providers uniformly despise RAC’s and view their heavy-handed tactics as torture during the audit process. As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Best regards,
Kirk Reinitz, CPA