CMS Issues Final RAC Rules

The Centers for Medicare & Medicaid Services (CMS) released the Medicaid Recovery Audit Contractor (RAC) program final rules and, the American Medical Association says, it appears the rules adopt many of the recommendations TMA, AMA, and 78 other state and specialty societies made in January.

According to AMA, the final rules:

  • Establish a three-year maximum claims look-back period;
  • Require RAC contractors to hire full-time physician medical directors and certified coders;
  • Require states to set limits on the number and frequency of medical record requests;
  • Order RACs to provide outreach and notify providers of audit policies and protocols;
  • Require RACs to accept submission of electronic medical records by fax or CD/DVD;
  • Prohibit RACs from auditing claims that have already been audited or are currently being audited by another entity;
  • Require RACs to return the contingency fee if an overpayment determination is reversed at any level of appeal;
  • Require states to adequately incentivize the identification of underpayments; and
  • Order states to coordinate the efforts of the RACs with other auditing entities. 

The final rule sets an implementation deadline of Jan. 1, 2012. 


Action, Sept. 16, 2011


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