The Medicare and Medicaid
programs employ a number of contractors to conduct audits of medical
providers. These contractors include the Medicare Administrative
Contractors (MACs), the Zone Program Integrity Contractors (ZPICs),
Comprehensive Error Rate Testing Contractors (CERT), Recovery Audit Contractors
(RACs), and in the case of Medicaid in Florida, the Agency for Health Care
Administration (AHCA), the Medicaid Fraud Control Units (MFCU), and the
Medicaid Audit Contractors (MICs).
The Medicare Administrative Contractor in
Florida is First Coast Service Options (FCSO). FCSO administers the
Medicare program payments in Florida for Parts A and Part B. In addition
to processing claims for payment submitted by medical providers, FCSO also
conducts medical review audits of claims submitted. These audits can be
either prepayment reviews, or post-payment audits.
The Zone Program Integirty Contractor
(ZPIC) in Florida is Safe Guard Services (SGS). SGS is tasked with
identifying potential fraudulent claims and providers. As part of its
benefit integrity function, SGS, along with its related contractor,
IntegriGuard, conducts prepayment review audits of Medicare providers.
The CERT contractors conducts post-payment
audits to determine the precentage of Medicare claims submitted that are
erroneous, that is, that should not have been paid.
Recovery Audit Contractors (RACs) are
private companies under contract with the Centers for Medicare and Medicaid
Services which have been tasked with identifying Medicare overpayments and underpayments
and returning Medicare overpayments to the Medicare Trust Funds. RACs review
claims submitted by health care providers and suppliers in an attempt to
identify improper payments. Because RACs receive a portion of the improper
payments they identify, the RACs are highly motivated to identify overpayments
and other improper payments.
The RAC program began as a three-year
demonstration program in 2005 in California, Florida and New York, the three
states with the highest Medicare expenditures. In 2007, the program expanded to
include Massachusetts, South Carolina and Arizona. The purpose of the RAC
demonstration program was to determine whether the use of RACs would be a
cost-effective way to identify and correct improper Medicare payments.
HPP
Management Group, Corp. represent and defend providers and suppliers in all
types of Medicare, Medicaid and other third party payer audits,
appeals and controversies. We have the knowledge and experience to assist
providers and suppliers in responding to audit requests in order to minimize
the number of initial denials, as well as to successfully appeal any improperly
denied claims. Please do not hesitate to contact us to discuss your particular
situation.
