Cognosante, LLC is the RAC for Missouri. Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or Cognosante, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
In 2015, the RAC will finish its work on outstanding pharmacy and durable medical equipment (DME) audits, and will begin conducting audits of hospital billing submitted by enrolled Missouri hospital providers. The RAC may request documentation to support billing of outpatient encounters, including professional and facility services. The RAC will review paid claims for proper billing of both professional and facility services, and the appropriate utilization of facility resources, such as supplies and facility charges. Documentation requests may include requests for itemized statements, medical records, medication administration records, radiology interpretations, and laboratory results to support the claims submitted for payment.
The RAC will begin issuing medical records requests to those hospitals selected for audit beginning July 2015.
In March, 2014, MMAC posted an update to the RAC (Recovery Audit Contractor) and MIC (Medicaid Integrity Contractor) activities on its website. See the archived post here March 2014 RAC and MIC update. Cognosante, LLC is the RAC for Missouri. Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or Cognosante, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
In 2015, the RAC will finish its work on outstanding pharmacy and durable medical equipment (DME) audits, and will begin conducting audits of hospital billing submitted by enrolled Missouri hospital providers. The RAC may request documentation to support billing of outpatient encounters, including professional and facility services in the emergency room. The RAC will review paid claims for proper billing of both professional and facility services, and the appropriate utilization of facility resources, such as supplies and facility charges. Documentation requests may include requests for itemized statements, medical records, medication administration records, radiology interpretations, and laboratory results to support the claims submitted for payment.
Missouri awarded its Recovery Audit Contractor (RAC) Contract to Cognosante, LLC. Under the purview of Cognosante, LLC, Arbor Healthcare has been contracted to perform Credit Balance Transfer Audit services for this contract. The Credit Balance audit process involves reviewing the financial payments made to patient accounts to ascertain the accuracy of the State’s reimbursement from the actual claims issued. Reviews/audits will not be conducted for third party liability (TPL) balances residing on patient accounts. The reviews/audits will focus on Medicare duplication of payments or other erroneous errors that do not pertain to TPL that may warrant a credit balance.
Arbor Healthcare’s approach to credit balance reviews begins with the Provider Relations staff (PRMs) communicating with the hospitals to schedule onsite audit visits at the billing office locations. The PRMs maintain communications with the hospital directors to ensure continued access to the facility and to enhance or expand the volume of days per month which the Arbor audit staff are allowed to visit the individual hospital facilities. Utilizing the state’s 1099 reports, Arbor Health will identify hospitals that generate significant Medicaid claims and should be candidates for credit balance reviews. Arbor Healthcare will work with the state to determine the hospitals to audit and frequency of on-site audits.
The actual Credit Balance audit phase begins by having an onsite field analyst visit each assigned provider location, allowing the analyst access to the providers’ complete payment record of each claim, and enabling the analyst to accurately resolve the errors, optimizing recoveries for Missouri Medicaid, and minimizing processing time and costs for payers and providers.
Arbor Healthcare then prepares review documentation that is presented to the Provider at the conclusion of the audit day, which documents the proper actions necessary to resolve the Credit Balance on the particular accounts reviewed by Arbor Healthcare. This review documentation includes “Refund Request” letters for any overpayment refunds that were identified. The Provider reviews the audit findings and has the ability to question the findings prior to the exit of Arbor from the facility.
The State has the ability to review all backup and claim calculations to determine its agreement with the refund rational, as well as the calculated refund value. The State will be able to signify its Approval/Denial via online selection or through downloading of Microsoft- based export files.
