Nothing stokes the darker recesses of the human imagination like a conspiracy theory.

Usually, a conspiracy theory begins with a confluence of facts leading to an unanswered question. From the Kennedy Assassination to the Bilderburg Group, lack of knowledge leaves the majority of people at the mercy of anyone who comes in to fill the void, no matter what the level of their actual knowledge or credibility on the subject.

With regard to RACs, we have one such knowledge gap that is becoming more glaring by the day based on the paucity of information currently in existence. I am writing of the RAC Validation Contractor (RVC).

Who are they? What shadowy deeds are they responsible for in this country? What darkened room with circular tables, 25 long-backed, padded chairs and a large video screen showing the world divided up into fief-like parcels holds this covert group of movers and shakers?

If only this entity was half as interesting.

Our investigation begins in Erie, PA (such a fittingly spooky name!), the “Flagship City” located in Northwestern Pennsylvania on the banks of the Great Lake that bears its name. It is in this city of roughly of 100,000 people where Provider Resources, Inc. (PRI) works as the only RVC.

PRI was named publicly by CMS as the RVC on October 9, 2008. It is on the CMS website where the search for further information begins.

According to the original announcement of PRI as the validation contractor, CMS works with PRI and the regional RACs to approve new issues RACs want to pursue in search of improper payments. In addition, PRI should be conducting accuracy reviews of RAC claims that have already resulted in overpayments being collected and returned to CMS. In a slide show available on CMS’s RAC Recent Updates page, it is stated that the RVC provides annual accuracy scores for each RAC.

Seeing this as a healthy head start in determining the work of the RVC, I decided to take a brief look at PRI. 

The following description of the services PRI renders as the RVC is taken directly from the company’s website:

….CMS looked to PRI to perform the critical quality control function of this program as the RAC Validation Contractor (RCV). In performing this work, PRI applies its considerable depth of Medicare knowledge and expertise on behalf of CMS to validate those efforts of the Medicare RACs. Our medical review teams—paired with our Medicare policy and procedures experts—audit the RACs’ determinations for Medicare claims which were paid under Part A or Part B of title XVIII of the Social Security Act. Through its reports to CMS, PRI ensures that the RACs are not unnecessarily denying Medicare claims which were properly paid. Similarly, our findings can also assure CMS that the RACs are properly recovering improperly-paid claims.

The above paragraph appears to be the usual self-aggrandizement often seen on the websites of small businesses and does very little to illuminate the full scope of the work PRI conducts as the RVC.

To set my mind in motion further, I contacted Scott Wakefield, the CMS Project Officer for Recovery Audit Operations for RAC Regions A & B with a few questions. I first asked about the idea of accuracy scores for the RACs, and was told that these scores would be released “along with the Annual Report to Congress in early 2011″. The release of this report will be announced on CMS’ RAC web page.

The second question I had was a blast from the recent past. I’ve decided to make it a mission of mine to nail down someone on defining “good cause”, since the term has been rendered meaningless by the current status of Palomar Medical Center vs. Sebelius, which states that good cause cannot be reviewed in an appeal by a provider based on the RAC statute. According to Mr. Wakefield, “…the RAC must establish good cause.  RACs and the RVC are required to comply with Reopening Regulations located at 42 CFR 405.980″. That’s an interesting comment, as the regulations in this portion of the Federal Register do not directly define good cause. The only references to good cause made in this section refer to appeal timelines from the original or subsequent determination of good cause. This just about proves that “good cause” remains largely undefined by both CMS and the RVC, and is better interpreted to mean “We look at whatever we want to because we said so. Nyah Nyah!”

CMS’ Annual Report to Congress will provide some picture about the work product of PRI in their capacity as the validation contractor. We know that the RAC rate of successful appeals in the Demonstration Project was conspicuously high. The RVC, which has so far been relatively invisible publicly to the quality control process, will be the internal line of defense to RAC improvement. Yet if the first rate of successful provider appeals is anywhere in the neighborhood of the numbers seen in the Demonstration Project, a few blinds over windows in an office in Erie, PA will more than likely open a little wider.

1:11 pm, December 15th, 2010 |