Long-term care groups applaud a pause in Medicare audits, urge permanent changes

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Long-term care stakeholders are praising the government's decision to temporarily pause the recovery audit contractor program, which is associated with a huge backlog of Medicare claims appeals.

The RAC program began in 2009, as a means of reviewing claims to detect and correct inappropriate Medicare payments. The Centers for Medicare & Medicaid Services now is in the process of awarding the next round of contracts to auditing organizations, and the agency has decided to effectively suspend reviews while it winds down the current round of contracts, according to information released Tuesday.

Today is the last day a recovery auditor may send a post-payment additional documentation request, according to the CMS memo. This means “effectively halting all auditing,” according to the American Coalition for Healthcare Claims Integrity, an association representing the auditors.

The auditors' group blasted the pause, saying that the RAC program recovers more than $1 billion in improper payments each quarter. Hospitals seeking less oversight and a “complicit” Congress have joined forces to undermine the program, which will hurt taxpayers and Medicare's solvency, the association stated.

However, healthcare providers say the RAC program is overzealous, leading to a staggering backlog of appeals that has overwhelmed the system. The exponential growth in appeals has swamped Medicare administrative law judges, and new cases will not be assigned to a judge for at least two years, the government recently announced.

The suspension offers a much-needed window to "begin to clear this backlog," said Larry Minnix, president and CEO of LeadingAge, in an email to McKnight's. 

The pause is a "welcomed next step" as long-term and post-acute care providers continue to press for "timely and appropriate initial Medicare claim processing and early appeal decisions,” said Mark Parkinson, CEO and president of the American Health Care Association/National Center for Assisted Living. 

The leaders of the large provider associations praised CMS' stated intention to “refine and improve” the program during this pause. It is unclear how long the suspension will last, according to the American Coalition for Healthcare Claims Integrity.

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