NC “RAC” Moves to Hospice: More Recoupments to Come

“RAC” is an acronym for Recovery Audit Contractor. PCG is North Carolina’s RAC. What does that mean? It means that PCG will review all past Medicaid payments (from prior years) to determine whether Medicaid overpaid (or underpaid) the health care provider. The reason NC is conducting these post-payment reviews is because the federal government (Obamacare) requires it.

In September 2011, the Centers for Medicare &Medicaid Services (CMS) published the Final Rule for RAC.  Mandated by the Obamacare, the Medicaid RAC Final Rule required states to implement their Medicaid RAC programs by January 1, 2012 or lose federal funding. RACs must follow federal and state guidelines to recover overpayments or to inform DMA of underpayments.

So for the past year, PCG has been auditing Medicaid payments to health care providers.  While the law requires PCG to determine underpayments and overpayments, I would venture to guess that the number of underpayments (where the State owes the provider more money) is less than 1% of the findings.  Maybe 0. Although maybe I don’t hear about the underpayments because, as a Medicaid lawyer, no one contacts a lawyer because the State pays them more money. But, if I were a gambling person, I would put my money on the fact that PCG is finding most, if not all, post payments were overpaid. I’d love to hear from a health care provider who received more money from the State as a result of being underpaid initially.

As of the end of November, PCG hasn’t audited hospice providers. Well, hospice providers, here comes PCG. Starting December 2012, PCG will be auditing hospice providers, specifically looking for providers who billed services concurrently with recipients who were receiving all-inclusive care.


About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on December 6, 2012, in Affordable Care Act, Hospice, Medicaid, Medicaid Recoupment, North Carolina, Obamacare and tagged , , , , , , , . Bookmark the permalink. Leave a comment.

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