OIG Blasts Medicare, RACs For Weak Oversight

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OIG Blasts Medicare, RACs For Weak Oversight
September 6, 2013 | By Alicia Caramenico


The Office of Inspector General has been critical of Medicare oversight in previous reviews, and Tuesday's report is no different. This week, the OIG claimed the Centers for Medicare & Medicaid Services may not be catching all overpaid claims and therefore allowing high amounts of improper payments to persist, MedPage Today reported.

The report found problems with CMS' action--or inaction--regarding improper payment vulnerabilities and referrals for potential fraud, as well as with RAC performance evaluations.

Medicare recovery auditors (RACs) reviewed 2.6 million claims in fiscal years 2010 and 2011 and identified roughly half of the claims with improper payments totaling nearly $1.3 billion.

While CMS identified 46 vulnerabilities that resulted in improper payments, it only took corrective action to address 28 of them and failed to evaluate the effectiveness of these actions. The OIG pointed out that by not evaluating corrective actions CMS can't determine if they effectively reduce improper payments.

Moreover, by June 2012, CMS still had not taken corrective action on the remaining 18 vulnerabilities that totaled $31 million in improper payments.

The report also showed CMS received six referrals of potential fraud from RACs but had not addressed them as of last November.

CMS also failed to evaluate RACs' performance on all contract requirements. For example, the performance evaluations did not assess RACs' timeliness or documentation requirements for referring potential fraud to CMS.
The OIG called on CMS to evaluate the effectiveness of corrective actions, review and take appropriate action on fraud referrals, and develop additional evaluation metrics to improve RAC performance--recommendations to which CMS mostly agreed, accoding to the report summary.

Last month, an OIG audit found the ability of CMS to recover billions of dollars in Medicare overpayments is hampered by poor record-keeping, as well as turnover among the contractors responsible for collecting overpayments. What's more, the agency is stuck with $543 million in "not collectible" overpayments, FierceHealthcare previously reported.

For more:
- here's the OIG summary and report (.pdf)
- read the MedPage Today article

Related Articles:
RAC medical record requests up 47%
OIG: CMS stuck with $543M in 'not collectible' overpayments
Providers ask Senate committee to rein in RACs
Health leaders to Congress: RACs inappropriately denying payments
RACs reclaim $1.37B in overpayments as criticism mounts


Thank You Ms Caramenico and Fierce Health Finance.

CMS Lowers RAC Medical Record Request Limits

Fierce Healthcare has;
CMS Lowers RAC Medical Record Request Request Limits
April 8, 2013 | By Alicia Caramenico


As hospitals and auditors clash over legislation to cap medical records requests for Medicare recovery auditors (RACs), the Centers for Medicare & Medicaid Services has adjusted the limits for additional documentation requests (ADR) in the RAC program, AHA News Now reported.

In particular, CMS has reduced the minimum number of documents RACs can request from hospitals and providers other than physicians and suppliers, according to the update issued Wednesday.

Starting April 15, RACs can request a minimum of 20 records in a 45-day period, down from the prior 35-record minimum.


CMS also lowered the limit for claim type; now RACs can only use 75 percent of a hospital's record request limit on a particular type of claim, such as inpatient, which is down from the previous 100 percent.

For example, if a hospital submitted inpatient, outpatient and inpatient psychiatric facility claims, the recovery auditor can use up to 75 percent of the ADR from one of those claim types, while the remaining 25 percent can be requested from any or all of the other types, CMS noted.

The agency also maintains its ability to give RACs permission to exceed the record request limits. The maximum number of requests per 45 days remains at 400. Providers with more than $100 million in Medicare severity diagnosis-related group payments still will have a cap of 600 documents.

The reintroduced Medicare Audit Improvement Act would cap additional documentation requests to 2 percent of hospital claims, with a maximum of 500 ADRs every 45 days, FierceHealthcare previously reported. The American Hospital Association has again given its support to the bill, which aims to alleviate the administrative burdens of handling medical record requests, especially for small, rural hospitals.

To learn more:
- here's the AHA News Now brief
- here's the CMS update (.pdf)
- check out the RAC program

Related Articles:
RAC denials a threat to hospitals and patients
Hospitals, lawmakers reaffirm calls for RAC reform
Most hospitals have 1 employee to handle RACs
Hospitals face increased RAC activity, denials

Thank You Fierce Healthcare and Ms Caramenico



Why don't we just issue an Executive Order - since there's obviously No Need for any type of Government Oversight with at Least $90 Billion a year being lost to fraud from Medicare - which grants Hospitals absolute immunity from any sort of investigation at all?

$90 Billion a year. 

Are we are supposed to believe that it would cost More to go Find it and recover it, than it's worth?