Reducing Improper Payments, Fighting Fraud, and Curbing Waste and Abuse under the Affordable Care Act

Final Rule Released for the Medicaid Recovery Audit Program On Wednesday, September 14, 2011 the Department of Health and Human Services (HHS) released its final rule for the Medicaid Recovery Audit Program, a key part of the Administration’s initiatives to curb waste, fraud and abuse. Created by the Affordable Care Act, the Medicaid Recovery Audit Program will help states identify and recover improper Medicaid payments. It will be largely self-funded, paying independent auditors a contingency fee out of any improper payments they recover that took place in the previous three years. The Recovery Audit Contractors (RACs) detect and correct past improper payments. RACs review claims after payments have been made, using both simple, automated review processes and detailed reviews that include medical records. RACs can only go three years back from the date the claim was paid, and are required to employ a staff consisting of nurses, therapists, certified coders, and a physician. Under these expansions, RACs will help identify and recover over and underpayments to providers across Medicare and Medicaid for the first time.

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