Hcs 490

Health Care Regulatory Issue-Fraud

Linda K. Braner

HCS430

01/28/2013

Professor Vanessa Williams, Esq.

Health Care Regulatory Issue-Fraud

Health care fraud is a major issue within the health care industry at the present time. To help combat this issue the Medicare Recovery Audit Contractor program (RAC) was established by the Centers for Medicare and Medicaid (CMS). The goal of RAC contractors is to reduce health care fraud in the United States. The article I chose for this week’s assignment “CMS Publishes Final Rule on Medicaid RACs” reveals the details of the newly established (2011) RAC for Medicaid. The guidelines for RAC contractors in both Medicare and Medicaid will help staff in health care understand what is expected of them and of their organizations, as well as help reduce health care fraud within those same organizations.

The Patient Protection and Affordable Care Act (PPACA), Section 6411, ("CMS Publishes Final Rule on Medicaid RAC's," 2011) is the law for which the guidelines for RAC were established. Effective January 1, 2012, all states were required to have “Medicaid RAC program in place” (CMS Publishes Final Rule on Medicaid RAC’s,”2011). The model for the state based Medicaid RAC programs is built from the Medicare RAC program.

The biggest difference between the Medicare RAC program and the Medicaid RAC program model’s is the Medicaid program variations from state to state. As many states have a variety of Medicaid HMO’s within their individual state, those separate state variants are considered to be a part of each state’s laws, not part of the federal laws for RAC programs ("CMS Publishes Final Rule on Medicaid RAC's," 2011). RAC guidelines require each state to prove that their individual programs meet the requirements set forth by CMS. These guidelines include having a licensed physician as the full time medical director, certified coders on staff and each program must demonstrate the technical ability to...