|SCOPE, AUDITOR, AND LOOK-BACK PERIOD|
Medicare zaqoverpayments and underpayments
|Medicare RACs are nationwide. The companies bid for federal contracts. They use post payment reviews to seek over and under payments and are paid on a contingency basis.||Region A: Performant Recovery
Region B: CGI Federal, Inc.
Region C: Connolly, Inc.
Region D: HealthDataInsights, Inc.
|Three years after the date the claim was filed.|
Medicaid overpayments and underpayments
|Medicaid RACs operate nationwide on a state-by-state basis. States choose the companies to perform RAC functions, determine the areas to target without informing the public, and pay on a contingency fee basis.||Each state contracts with a private company that operates as a Medicaid RAC.
In NC, we use PCG and HMS.
|Three years after the date the claim was filed, unless the Medicaid RAC has approval from the state.|
Medicaid overpayments and education
|MICs review all Medicaid providers to identify high-risk areas, overpayments, and areas for improvement.||CMS divided the U.S. into five MIC jurisdictions.
New York (CMS Regions I & II) – Thomson Reuters (R) and IPRO (A) • Atlanta (CMS Regions III & IV) – Thomson Reuters (R) and Health Integrity (A) • Chicago (CMS Regions V & VII) – AdvanceMed (R) and Health Integrity (A) • Dallas (CMS Regions VI & VIII) – AdvanceMed (R) and HMS (A) • San Francisco (CMS Regions IX & X) – AdvanceMed (R) and HMS (A)
MICs are not paid on a contingency fee basis.
|MICs may review a claim as far back as permitted under the laws of the respective states (generally a five-year look-back period).|
Medicare fraud, waste, and abuse
|ZPICs investigate potential Medicare FWA and refer these cases to other entities.
|CMS, which has divided the U.S. into seven ZPICs jurisdictions.
Only investigate potential fraud.
ZPICs are not paid on a contingency fee basis.
|ZPICs have no specified look-back period.|
Medicaid fraud, waste, and abuse
|MFCUs investigate and prosecute (or refer for prosecution) criminal and civil Medicaid fraud cases.||Each state, except North Dakota, has an MFCU.
Contact info for NC’s:
Medicaid Fraud Control Unit of North Carolina
|MFCUs have no stated look-back period.|
Medicare improper payment rate
|CERT companies indicate the rate of improper payments in the Medicare program in an annual report.||CMS runs the CERT program using two private contractors (which I am yet to track down, but I will).||The look back period is the current fiscal year (October 1 to September 30).|
Medicaid improper payment rate
|PERM companies research improper payments in Medicaid and the Children’s Health Insurance Program. They extrapolate a national error rate.||CMS runs the PERM program using two private contractors(which I am yet to track down, but I will).||The look back period is the current fiscal year (the complete measurement cycle is 22 to 28 months).|
As you can see, the soup is flooded with letters of the alphabet. But which letters are attached to which audit company determines which rules are followed.
It is imperative to know, when audited, exactly which acronym those auditors are
Which brings me back to my original story of my dental provider, who was audited by a “non-RAC” entity for claims 5 years old.
What entity could be performing this audit, since PCG was not acting as its capacity as a RAC auditor? Let’s review:
- RAC: AG claims no.
- MIC: This is a state audit, not federal. No.
- MFCU: No prosecutor involved. No.
- ZPIC: This is a state audit, not federal. No allegation of fraud. No.
- CERT:This is a state audit, not federal. No.
- PERM: This is a state audit, not federal. No.
If it walks like a duck, talks like a duck, and acts like a duck, it must be a duck, right?
Or, in this case, a RAC.