Affordable Care Act Triggers RAC Expansion to Medicaid, Medicare Advantage and Part D

"Can You Hear Me (Us) Now??!"

I wish I had coined that phrase years ago! So many of us responsible for education, training and consulting within the healthcare industry feel that we sometimes speak to deaf ears regarding some basic components related to payment and reimbursement, documentation, medical coding, claim creation, billing and compliance. If you have not really "heard" and taken substantive action to improve in these areas, now is the need to hear me (us) now!

The Affordable Care Act (ACA)

The new Affordable Care Act (aka Healthcare Reform), signed into law in March 2010, has changed and will continue to change the face of all aspects of healthcare for patients, organizational providers, physicians and payers (lots of ‘p's there). Some provisions of the act are gaining more notoriety than others, with the total package not yet even fully developed or understood. Some in our industry are hoping it will "go away" or be revised in the future so we can say now that "we really don't have to DO anything about it, and we have enough to contend with these days anyway!"

Ok, let's be clear...we all MUST take notice of certain components of this legislation and address our internal issues NOW, because tomorrow truly will be too late; the still-new RAC program is but a portend of things to come!

In a letter dated June 8, 2010 from HHS Secretary Kathleen Sebelius to Attorney General Eric Holder, she underscored certain components of the Affordable Care Act about which we must all sit up and take notice: "the President has directed the Department of Health and Human Services (HHS) to cut the improper payment rate, which tracks fraud, waste and abuse in the Medicare Fee for Service program, in half by 2012."

What You MUST Hear?!

The Affordable Care Act will improve and expand government-wide healthcare initiatives by identifying and fighting fraud and waste, and it includes new tools to prevent, detect and take action against fraud in Medicare, Medicaid, the Children's Health Insurance Program (CHIP) and also private insurer enterprises. The act also amends the False Claims Act to provide that a violation of the latter's anti-kickback statute constitutes a fraudulent action. The new act defines an "overpayment" as "any funds that a person receives or retains (from a federal payer) to which the person, after applicable reconciliation, is not entitled."

Through "Expanded Overpayment Recovery Efforts - the Secretary (of HHS) (has) provided new authorities to identify and recover overpayments through the expansion of the RACs to Medicaid, Medicare Advantage and Part D (the Medicare drug benefit). Providers, suppliers, Medicare Advantage Plans and Part D Plans must self-report and return Medicare and Medicaid overpayments within 60 days of identification."

(See for a summary or the key points in the ACA.)


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