GAO Says CMS Must Do Better

“Weakness Remains”

The Government Accounting Office (GAO) released a report on March 31, 2010, which discussed the Centers for Medicare & Medicaid Services’ (CMS) RAC process.

The report mentions the RAC pilot program and the RAC process in general and essentially says this program is working.

The report then goes on to say, there shouldn’t be a need for the RAC program:

CMS did not establish an adequate process in the 3-year demonstration project or in planning for the national program to address RAC-identified vulnerabilities that led to improper payments, such as paying duplicate claims for the same service.  CMS stated that one purpose of the demonstration project was to obtain information to help prevent improper payments. However, CMS has not yet implemented corrective actions for 60 percent of the most significant RAC-identified vulnerabilities that led to improper payments, a situation that left 35 of 58 unaddressed.

The GAO findings go on and can really make on ill as you get a view inside the incompetence of government programs.

Basically what this report is saying is, the RAC program is working, but we shouldn’t need the RAC program, the CMS should have it’s act together so it doesn’t screw up this bad.

The GAO then goes on to recommend action to fix the CMS shortfalls.  Unfortunately the actions are bland governmental reactions: “the Administrator of CMS should develop and implement a process that includes policies and procedures…” and “The Administrator of CMS should designate key personnel with appropriate authority to be responsible….”

Unfortunately typical government mumbo-jumbo.

Let’s face it, the CMS isn’t going to change how it works, and the RAC process is the “easy” way to attack this problem.

Quite frankly, we at RACGuru don’t see things changing…aside from the RAC’s coming after more and more physicians.

CMS Record Request Limits Increased

The CMS, bending to the RAC blood suckers, has set an increase in the maximum number record requests every 45 days from 200 to 300 starting April 1, 2010 (April Fools anyone?).

Additionally, the CMS is making more clear how they define an organization of more than 1 phycisian – take heed all ye who live by the mantra “this is a hospital issue” – why would the CMS clarify – nay – expand their definition of a physicians group is this was merely a hospital issue.

Here a breakdown of the update from CMS – definitions are below (Read the actual update yourself here):

  • Campus Unit – this really only affects practices with multiple locations.  As long as you have a single physical location OR your other locations are nearby – the first 3 digits of the zip code are the same.
  • Request limits are bases on 1% of all claims submitted (including Professional Services), it does not mater if the claim was paid out or not, but that total number submitted.
    • Remember: a RAC can hit you up every 45 days
    • Also this gem – “the RAC may exercise discretion in the exact composition of an additional documentation request” – meaning the RAC can go after any part of your business, no matter what percentage overall of your practice it is.
  • 2 limit caps in FY2010 (no need to simplify things):
    • Through March 2010 the limit is 200 ADR’s every 45 days
    • Starting April 2010 the limit goes up to 300 ADR’s every 45 days.
    • Sparkling gem #2:
      • “in FY 2010 CMS will allow the RACs to request permission to exceed the cap”

CMS – Centers for Medicare & Medicaid Services
ADR – Additional Documentation Request
RAC – Recovery Audit Contractor
FY – Fiscal Year