General

For the Week of February 8, 2016

Will RACs ever investigate Part C Medicare Advantage claims? 

Although Congress mandated a Part C (Medicare Advantage) recovery audit contractor (RAC) in the Patient Protection and Affordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) just got around to issuing a request for information (RFI). 

As CMS currently envisions it, the Medicare Part C RAC will undertake two types of audits: comprehensive risk-adjusted data validation (RADV) and condition-specific RADV. The Medicare Advantage organizations will submit medical record documentation to CMS for each of the diagnoses that they reported for each enrollee in the audit sample. CMS also plans to extrapolate an overpayment estimate for each audited contract and recover money based on this estimate.