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Demonstration Project
Dates & Deadlines
Statement of Work
Audit & Denial Types
Medicaid RACs
100
This three-year long project lasted until 2008, and returned over $900 Million in overpayments to the Medicare Trust Fund.
What was the RAC Demonstration Project?
100
Section 302 of the Tax Relief and Health Care Act of 2006 made the Recovery Audit Program permanent and required the Secretary to expand the program to all 50 states no later than this date.
What was January 1, 2010?
100
This position at a RAC must be filled by either a Doctor of Medicine or a Doctor of Osteopathy who has relevant work and educational experience.
What is the Recovery Auditor Medical Director?
100
This occurs when a RAC makes a claim determination at the system level without a human review of the medical record.
What is an Automated Denial?
100
On September 16, 2011, CMS published the final rule implementing this program, with an effective date of January 1, 2012.
What is the Medicaid RAC Program?
200
This maximum for this fee was 25% of the full amount recovered by the contractor.
What was the contingency fee for the RACs during the Demonstration Project?
200
This limit is 60 days from the date the RAC receives the requested medical record documentation from the provider.
What is the time limit to complete a Complex Review? Or, how long can the RAC take to complete a Complex Review?
200
This process/period must be immediately ended, once an appeal has been filed by the provider.
What is the Discussion Period?
200
This type of determination refers to a complex review performed by the RAC in the absence of a written Medicare policy, article, or coding statement, requiring the RAC to utilize appropriate medical literature and apply appropriate clinical judgment.
What is “individual claim determination”?
200
On December 30, 2011, authorized States to pay their respective Medicaid RACs a contingency fee up to this percentage, the current highest contingency fee paid to Medicare Recovery Auditors, for the recovery of improper payments made for “medical supplies, equipment and appliances suitable for use in the home” found within the home health services benefit authorized by section 1905(a)(7) of the Social Security Act.
What is 17.5%?
300
The RAC got to keep their fee, even if this process went against them, for any reason, thereby overturning their denial.
What is the Appeal process?
300
Interest can be added to the recoupment amount of any verified overpayment beginning on this date.
What is 30 days after the date of the Demand Letter?
300
Section 935(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 amended the Social Security Act to provide a limitation on this process.
What is (the Limitation on) Recoupment?
300
This type of review has no limits placed on the number of Additional Documentation Requests that can be made of a provider.
What is a Semi-Automated Review?
300
The Final Rule at 42 CFR § 455.506(e) provides that a State must set limits on this kind of request, but the State has flexibility to determine such limits. CMS will not prescribe a set limit for a Medicaid RAC.
What is ADR or Records Request Limits?
400
$38,000,000
What was the total amount of underpayments returned to providers during the Demonstration Project?
400
Offset or Automatic recoupment for an overpayment can be implemented on this date.
What is day 41 or 41 days after the date of the Demand Letter?
400
The RAC will not receive any contingency fee for this type of refund made by a provider.
What is an unsolicited/voluntary refund?
400
This code means that a claim was denied without reviewing the medical record because the requested records were not received or were not received timely in a timely fashion.
What is remittance advice code N102?
400
CMS is not requiring States to publicize the audit areas on which their Medicaid RACs will focus. However, CMS encourages States to promote this feature in their RAC programs.
What is transparency or posting audit issues for providers to see, before the RACs can pursue those issues.
500
California , Florida , New York , Massachusetts , South Carolina and Arizona.
What were the first six states where the Demonstration Project was conducted?
500
To prevent offset, this process must be filed within 30 days, and in no case may it be submitted after 120 days of receipt of the demand letter.
What is the Redetermination period?
500
A RACs only receive 75% of their fee for the recovery of a Part A claim when this process is used.
What is the offset process?
500
This is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented.
What is Clinical Validation?
500
There may be a potential conflict of interest if the same entity acts as both Medicaid RAC and as this kind of contractor, since RACs are compensated based upon the amount of overpayments identified, and this could consequently impair the ability of the same entity to adequately measure payment error rates.
What is a PERM contractor?