Health Information Management

News: Proposed rule on Medicaid RACs sets April 2011 as start target

CDI Strategies, November 11, 2010

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CMS released the long-anticipated proposed rule for Medicaid recovery audit contractors (RACs) Friday November 5, setting the stage for the targeted April 2011 implementation date.

The use of Medicaid RACs is another initiative put forth by CMS as part of the Affordable Care Act—implemented earlier this year—designed to identify waste, fraud and abuse in the healthcare system by reducing improper payments. According to the rule, states must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010 and fully implement their programs by April 1, 2011.
The Medicaid RAC program will not be the same as current RAC program for Medicare, says Joe Zebrowitz, MD, executive vice president for Executive Health Resources. Because Medicaid programs are state-governed the Medicaid RAC program will likely apply rules differently, state-by-state. This means that not only will the appeals process be different from the RAC appeals process for Medicare but that it will also differ from state to state.
“The partnership between the states and CMS in administering the Medicaid program makes the program so different that while there may be some general lessons to be learned from the Medicare RAC program, the influence of state law and the intricacies of each state’s Medicaid program will make these Medicaid RACs function very differently,” says Sara Kay Wheeler, partner at King & Spaulding LLP in Atlanta.
So, what is the next step for providers when it comes to preparation for Medicaid RACs? According to Zebrowitz, the answer is two-fold:
“First, make sure you are as rigorous in your Medicaid admission review process as you are in your Medicare admission review process. Recognize that the rules may be different compared to Medicare and familiarize yourself with the specific differences,” he says. “Next, you’ve got to come up with a way to manage the process concurrently and to ensure you are arriving at a compliant admission status up front, and manage retrospectively to ensure your protection of rights within the potentially lengthy appeals process.”
Editor’s note: This article was originally issued as a breaking news alert. Read the complete article at The Revenue Cycle Institute.

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