The South Carolina Medicaid Recovery Audit Contractor is Back: Resources and Practical Response Tips
After a lengthy absence, the South Carolina Department of Health and Human Services (“SCDHHS”) announced on September 10, 2024, that its Medicaid Recovery Audit Contractor (“RAC”) program was resuming on October 1, 2024.[i] SCDHHS awarded the Medicaid RAC contract to Health Management Services (“HMS”), a recovery audit contractor, which will conduct place of service reviews, diagnosis-related group claim reviews, and payment analytics reviews.[ii] HMS will also be conducting Medicaid Credit Balance Audits.[iii]
The stated purpose of the RAC program is to assist states in identifying and recovering overpayments, which might be caused by billing and coding errors, failure to coordinate benefits, overutilization, or fraud and abuse.[iv] Providers are required to pay back overpayments identified, but will also have full appeal rights to challenge alleged overpayments.
SC Medicaid RAC Resources. SCDHHS has a series of readily available resources, including the following:
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Place of Service (“POS”) Solution and Review Process |
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| Provider Outreach and Education |
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| POS Review Information Sheet |
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| DRG Validation Review Sheet |
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| DRG Clinical Audit and Review Process |
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| HMS Credit Balance Audit |
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| FAQ and Contact Info |
Links to all the above resources are available on the SCDHHS website.[v]
Practical Response Tips to Prepare for Medicaid RAC Audits. As RAC audits resume, a few simple steps can help ensure an orderly and effective RAC response process.
| Conduct internal review of Medicaid RAC targets |
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| Review process for receiving audit requests |
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| Designate appropriate person to review all incoming audit requests |
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| Calendar and meet all deadlines |
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| Review process for producing records and information |
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| Build an Audit Response Team |
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In summary, with the South Carolina Medicaid RAC Program resuming on October 1, the best advice is to know who the RAC is, what the RAC is auditing, and how you anticipate responding to new SC HMS RAC requests.
If you need assistance with navigating South Carolina Medicaid RAC or other payor audits or requests, please reach out to Maynard Nexsen for assistance.
[i] https://www.scdhhs.gov/communications/south-carolina-recovery-audit-contractor-0#:~:text=The%20purpose%20of%20the%20RAC,services%20or%20fraud%20or%20abuse.
[ii] Id.
[iii] https://www.scdhhs.gov/sites/default/files/HMS%20Credit%20Balance%20Audit%20Medicaid%20Overview%20-%20Updated%2005122021.pdf
[iv] Id.
[v] https://www.scdhhs.gov/medicaid-recovery-audit-contractor
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