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Not Just RACs: Providers Must Prepare for MICs Too

James Carroll, February 16, 2010

Providers nationwide are certainly familiar with Recovery Audit Contractors, or RACs. But perhaps less familiar are Medicaid Integrity Contractors, or MICs. These MICs have yet to hit every state, but the program will be rolled out to the entire country this year and audits are now under way or coming soon.

In light of the nationwide MIC rollout, CMS recently updated its Web site with three informative notices to help providers understand key concepts and timelines.

In 2005, the Deficit Reduction Act created the Medicaid Integrity Program in section 1936 of the Social Security Act, which increased government responsibility pertaining to Medicaid fraud and abuse. Section 1936 requires CMS to contract four program integrity focuses: Reviewing provider actions; audit claims; identifying overpayments; and educating providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care.

As a result of this requirement, CMS entered into contracts with a number of entities to perform those functions. These contractors are known as MICs, and there are three different types (education, review, and audit MICs) whose goal is to identify Medicaid fraud and abuse by auditing claims and identifying overpayments.

The goal of audit MICs is similar to that of RACs, which is to identify improper payments and ultimately decrease the inappropriate payments altogether. However, there are a number of differences between the two contractors, starting with the fact that MICs have no set medical request limits, while RACs have a 200 per 45 day limit.

MICs also base the length of lookback guidelines on individual state guidelines, while RACs have a set period of three years. Additionally, MICS aren't paid by contingency fee like RACs; they are compensated through a sort of fee-for-service model where they are eligible for bonuses based on how effectiveness and efficiency, according to CMS.

CMS has divided the country into distinct regions, each with its own MIC, in order to streamline the process. The regions are as follows:

  • Regions I/II: Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Puerto Rico, Rhode Island, Vermont, and the U.S. Virgin Islands. The MIC for this region is Thomson Reuters.

  • Regions III/IV: Alabama, Washington D.C., Delaware, Florida, Georgia, Kentucky, Maryland, Mississippi, North Carolina, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia. The MIC for this region is Thomson Reuters.

  • Regions V/VII: Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, and Wisconsin. The MIC for this region is AdvanceMed.

  • Regions VI/VIII: Arkansas, Colorado, Louisiana, Montana, North Dakota, New Mexico, Oklahoma, South Dakota, Texas, Utah, and Wyoming. The MIC for this region is Thomson Reuters.
  • Regions IX/X: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Northern Marianna Islands, Nevada, Oregon, and Washington. The MIC for this region is Thomson Reuters.

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