Medicaid Recovery Audit Contractor (RAC) Provider Reviews

Pursuant to Federal law, 42 U.S.C. § 1396a(a)(42); 42 C.F.R. § 455.500 et seq., the Commonwealth of Pennsylvania, Department of Human Services (department), Bureau of Program Integrity (bureau) has contracted with Health Management Systems, Inc. (HMS) as Pennsylvania’s Medicaid Recovery Audit Contractor (RAC) to review claims submitted by providers of items and services or other individuals furnishing items and services for the purpose of identifying underpayments and overpayments and recouping overpayments under the State plan and under any waiver of the State plan with respect to all services for which payment is made to any entity under such plan or waiver.
In accordance with 42 C.F.R. § 455.506:

  1. HMS will augment the bureau’s reviews within the Fee-for-Service Program.
  2. The department will coordinate with HMS regarding the recoupment of overpayments in the following manner. After review of the claims and documentation provided, HMS will issue a notice of preliminary review findings to the provider with the option for the provider to submit additional information to dispute the finding(s). HMS will consider any additional documentation received in making its recommendation for a final determination to be made by the department, and the department will issue a notice of final review findings and underpayments and overpayments. In order to recoup overpayments, the department will complete claim voids and adjustments through the MMIS system when possible; providers should submit a check for the overpayments only when directed by the department.
  3. The department and HMS will coordinate recovery audit efforts with other contractors or entities performing audits of entities receiving Medicaid payments.
  4. he department will make referrals of suspected fraud and/or abuse to the Office of Attorney General, Medicaid Fraud Control Section or other appropriate law enforcement agency.
  5. HMS will issue requests for copies of medical records at a frequency not to exceed 100 records per month.