Medicare RAC Focuses on Medicare Advantage, Prescriptions

Medicare Recovery Audit Contracting has made great strides in recovering millions of dollars lost to waste and fraud in the past few years. Its success with the new areas of Medicare Advantage (Part C), Medicaid, and prescription drug coverage (Part D) as spelled out earlier this year under the new healthcare reform law, is uncertain according to those testifying last week before a Senate panel.

These expansions will take the RAC Medicare program beyond Medicare fee-for-service for the first time by Dec. 31, said Deborah Taylor, head of the Office of Financial Management at the Centers for Medicare & Medicaid Services. But while the "RACs proved effective and relevant" to Medicare fee-for-service, "it remains to be seen how this effort will translate into other programs."

"Each of these programs are administered and reimbursed differently and present their own unique challenges," she testified before the Senate Homeland Security and Governmental Affairs' Subcommittee on Federal Financial Management, Government Information, Federal Services and International Security. Medicaid in particular will create new demands since there are more than 50 programs found in the states and territories.

An audit by the Department of Health and Human Services Office of Inspector General (OIG) discovered that "Medicare does not have a strong process" to ensure valid identification numbers on reimbursed prescriptions under the drug program, said subcomittee head Sen. Tom Carper (D-DE).

However, the Office of the HHS Inspector General (OIG) recently found that safeguards for indentifying claims with invalid prescriber numbers were not functioning correctly for Part D claims, Vito said. These problems with Part D actually paralleled problems encountered over the past decade with Medicare Part B for medical devices.