What is the RAC program?
Under Section 6411(a) of the Affordable Care Act, 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 and 10 CCR 2505-10, Sections 8.050 and 8.076.
The Colorado Department of Health Care Policy and Financing (Department) contracted with CGI Federal, Inc., to be its RAC vendor through June 30, 2013. The Department is conducting a procurement process for a new RAC vendor. The Department anticipates to have a contract signed by July 1, 2014.
RAC Audit Scope
Once a new contract is signed, the RAC vendor 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.
The RAC vendor will be conducting post-payment claims reviews on behalf of the Department.
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. The RAC 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.
Are providers required to cooperate with the RAC?
Providers are required by Section 1902(a)(27) of the Social Security Act and 10 CCR 2505-10, Section 8.130 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.
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 and who do I contact with RAC questions?
Contact Kim Nguyen, Contingency Based & Recovery Audit Contract Manager, with any questions at Kim.Nguyen@state.co.us or 303-866-6575.