Recovery Audit Contractor (RAC) Program
What is the RAC program?
Under Section 6411 of the Patient Protection and Affordable Care Act (ACA), each state must contract with a contingency-fee-based vendor to review provider claims. The purpose of the review is to reduce improper Medicaid payments through the efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments. See also CRS Section 25.5-4-301(3)(a), (a.5), (b) and Section 25.5-4-301(3.5); and 10 CCR 2505-10, Section 8.050.6.
The Colorado Department of Health Care Policy and Financing (Department) has contracted with CGI Federal, Inc., to be its RAC vendor.
RAC Audit Scope
CGI Federal will audit the following types of claims: Medicaid Fee-For-Service, Medicaid waiver services, Medicaid Managed Care, and Child Health Plan Plus (CHP+). Inpatient hospital claims are excluded.
Types of Audits
There are two types of audits: post-payment claims reviews and credit balance reviews.
A post-payment claims review is an evaluation of a provider submitted claim to determine if the services were actually provided, medically necessary, coded correctly, and properly paid or denied. CGI Federal will identify both overpayments and underpayments in its audits. Post-payment claims reviews may include review of medical records or a review of claims data only.
A credit balance review is an evaluation of a provider's financial accounts and receivables to determine if all credits and third party payments have been appropriately credited and refunded to the Department.
Are providers required to cooperate with the RAC?
Providers are required by Section 1902(a)(27) of the Social Security Act and 10 C.C.R. 2505-10, Section 8.130.2.A to:
- Retain records necessary to disclose the nature and extent of services provided to recipients.
- Maintain records which fully substantiate or verify claims submitted for payment.
- Submit records to federal and state government upon request.
How will providers know if any of their claims have been selected for audit?
CGI Federal will send providers a letter requesting a copy of their medical records to support claims under review.
What do providers need to do?
Providers need to submit all requested medical records and supported documents within 45 calendar days of the request date in either electronic or hard copies.
Providers are responsible to submit all requested information in a timely manner.
Providers need to update the Department with their most current and accurate contact information.
What happens if the provider does not cooperate?
Any claims for which documentation is not received upon request shall be deemed to be overpayments subject to recovery regardless of whether or not services were provided.
The Department will recover the overpayments.
Where can I find out more information?
Providers can go to the CGI Federal Web site.
Who do providers call with RAC questions?
Contact Kieu Pham, Audits and Compliance Division, with any questions at BichKieu.Pham@state.co.us or 303-866-2022.