As I type this, I have one foot out the door as I prepare to travel to Oklahoma City, Oklahoma to present at the 12th Annual National Conference of the American Medical Billing Association. Yes, the topic is government audits, and yes, since it’s Wednesday, I have some new information on this front.
Today’s topic is Medicaid Recovery Audit Contractors. In looking at the contracts that have been awarded, it appears that pluralizing the word “contractor” is an exercise in futility, because HMS is far and away the Medicaid RAC of choice. HMS, or their subsidiaries, have been awarded, or are about to be awarded 28 state contracts, either as a primary contractor or subcontractor, at last count. Ergo, it should come as no surprise that they appear to be the first ones out of the block nationally to begin conducting actual Medicaid RAC audits.
Because an approved issues listing can be provided at a state’s discretion based on the Medicaid RAC final rule, there is no definitive way to ascertain what the Medicaid RAC in any state would be reviewing. Knowing this, it becomes extremely important to gain knowledge and insight, by any means possible, as to what the Medicaid RACs are auditing. Thanks to readers sharing information, as well as information that is hitting my desk from other sources, the knowledge I am gaining should give the provider community pause.
It appears that the Medicaid RACs are targeting coverage and payment issues out of the gate. As an example, in one state, if a state Medicaid agency has made a payment at a time when the patient was covered by a Medicaid HMO, they are requesting money back from the providers. Given that the RACs can go back three years to identify such claims, timely filing issues rise to the surface in a rather stark fashion.
In my opinion, this type of audit is penalizing providers needlessly. What the RACs are saying, in essence, is that the provider was entitled to the amount paid, but because the provider did not have a clear picture of a Medicaid patient’s ever-shifting eligibility and coverage, that money should now be forever forfeited. The better use of resources in these cases would be for the state Medicaid agencies to subrogate these payments with the Medicaid HMOs that should have made payment in the first place. Instead, the provider, who is already meagerly compensated for caring for the Medicaid patient, now gets nothing. Is this really the message CMS wants to send to the provider community as the medical delivery system stands on the brink of a massive Medicaid population expansion thanks to PPACA?
In addition, it appears that incorrect Part B coinsurance payments to providers are being targeted. Providers in some states are receiving CDs with listings of patients for which the incorrect payment is alleged to have been made by Medicaid. Upon first review, some of these determinations are correct, but there are some that appear to be incorrect readings of the original secondary explanation of benefits issued by Medicaid. This continues the long-standing “literacy-optional” policies for most state Medicaid agencies as applied to their claims adjudication staff.
I thank the readers who have provided feedback to me as to what the Medicaid RACs are reviewing. In the spirit of sunshine being the best disinfectant, I invite all of the readers of this space to continue to share with me this information. It was learned rather belatedly that information sharing is of paramount importance as it applies to Medicare RAC issues, and so the same applies to Medicaid RACs. I may be going out of town, but I’m never out of touch, and I thank you all for your continued attentions.