Medicare Improper Payment Review - Recovery Auditor Contractors(RAC)

Summary of Program
The Recovery Audit Program's mission is to reduce Medicare improper payments through the efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments. Section 302 of the Tax Relief and Health Care Act of 2006 requires the Secretary of the Department of Health and Human Services to utilize Recovery Auditors under the Medicare Integrity Program to identify underpayments and overpayments and recoup overpayments under the Medicare program associated with services for which payment is made under part A or B of title XVIII of the Social Security Act. The Act Requires a permanent and nationwide RAC program and gave CMS the authority to pay the RACs on a contingency fee basis. The RACs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments. If you bill fee-for-service programs, your claims will be subject to review by the RACs. RACs are required to employ a staff that consists of nurses, therapists, certified coders, and a physician CMD.

RAC Review Process
RACs review claims on a post-payment basis and will be able to look back three years from the date the claim was paid. There are two main types of review - automated (no medical record required) and complex (medical record required). Issues reviewed by RACs will be approved by CMS and be publicly available on the RAC website for review. RACs will accept imaged medical records on CD/DVD.

The collection process for the RAC is the same as process used by carriers, FI and MAC identified overpayments. The RAC will issue a demand letter and then offer an opportunity for the provider to discuss the improper payment determination with the RAC. If providers agree with the RAC's determination they can pay by check, allow recoupment from future payments, or request or apply for extended payment plan. If providers disagree, there is an appeals process to follow. Practices must file an appeal before the 120th day after the RAC Demand letter is sent.

OIG 2015 Work Plan
The U.S. Department of Health & Human Services (HHS) released the Office of Inspector General (OIG) 2015 Work Plan on October 31, 2014. The OIG Work Plan summarizes the objectives for HHS planned areas of focus for investigation and enforcement activities. The majority of the items in the report are ongoing reviews with just a few new activities the Office of Inspector General (OIG) will pursue in the coming year and beyond. Summary of the areas of focus for 2015.

Links to Programs
Each Recovery Auditor is responsible for identifying overpayments and underpayments in approximately ¼ of the country. The Recovery Audit Program jurisdictions match the DME MAC jurisdictions.

The Recovery Auditor in each jurisdiction is as follows:
Region A: Diversified Collection Services (DCS)

  • States: CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI and VT.
  • Website: dcsrac.com
  • Email: info@dcsrac.com
  • Phone number: 1-866-201-0580

Region B: CGI

  • States: IL, IN, KY, MI, MN, OH and WI.
  • Email: racb@cgi.com
  • Phone number: 1-877-316-7222

Region C: Connolly, Inc.

Region D: HealthDataInsights, Inc.

Additional Information & Resources