Recovery audit contractors, whose job it is to “recover” Medicare dollars, prove time and time again that they are quite efficient in their job. We have all been inundated with “statistics” that show the staggering dollars they have recovered, most notably for long term care through the disastrous Manual Medical Review Part B claim review process.

When I came across the guest column by Kristin Walter last week in McKnight’s on “Are new RAC ADR limits fair to providers?” I was at first, frankly, confused. The Council for Medicare Integrity is concerned for providers?  

In reading the column, I quickly I realized the spin, which is not too different than the spin put on RAC recovery success. It truly has nothing to do with provider protection.  No, this was about the limited potential for RACs to save the Medicare program. As Walter writes, “the new ADR limits will have a huge negative impact on the longevity of the Medicare program [SINCE] auditors will look at even fewer claims and return much less to the program.” (Emphasis mine)

She goes on to cite statistics about RAC recovered dollars in the billions and forecasts the doom of Medicare to bankruptcy by 2030.

Let’s talk about these billions in recovered dollars. On face value this casts continued negative light on Medicare providers which plays well into the RACs successful role of getting the bad guys. But there is one HUGE problem. These recovered dollars or denied claims, although determined to be overpayments or inaccurate payments, have not withstood the test of time. By time, I mean the now years necessary to successfully participate and complete the Medicare Appeals process through to the Administrative Law Judge. I don’t have to remind you that many SNF claims are in the ALJ black hole somewhere in a “galaxy far far away.”

Therefore, how statistically meaningful is this billion dollars in recovered Medicare funds when we do not know the final outcome? Shouldn’t we report on denied claims by RACs that have either resulted in the rights to further appeal being surrendered or received an ALJ decision? This seems to be the most important needed statistically accurate number so that we all know where we stand in the big picture of “good or bad” provider AND whether or not Medicare solvency can truly be achieved in the long run from RAC recovered funds.

The flaws in the system to rely on recovered dollars to keep Medicare solvent and at the same time fairly measure and review Medicare providers cannot be ignored. Medicare providers understand the rules of providing services to Medicare clients which include accountability to accurate and supported billed claims.  Using “fuzzy math” though, helps none of us.

Next steps are critical in the coming days. The long-term care industry and its supportive organizations continue to be in dialogue with CMS, who thankfully has been accommodating to hear from us, to hopefully ensure a fair and measurable implementation of the medical review process which includes changes in sample volume and parameters like denial rate.  

NO medical review process that is based on “fuzzy math” is acceptable. Are there bad guys? You bet there are! But right now we don’t really know who the bad guys are.

Tara Roberts, PT, is the Vice President of Rehabilitation and Wound Care Services at Nexion Health.