Part D RAC Audits
- CMS/CPI determines specific criteria for the RAC to review audit packages, including the plan, year and audit issues to be reviewed
- In addition to the audit issues already approved (excluded providers, duplicate payments, DIR) proposed new audit issues undergo a thorough, multi-step, multi-party vetting process prior to approval. CMS/CPI limits audit issues to a maximum of five per year.
- The RAC conducts improper payments analyses and impact calculations based on audit data provided by CMS
- Cases of suspected fraud are referred directly to the Medicare Drug Integrity Contractor
- The RAC's findings undergo in-depth review and analysis by its Data Validation Contractor (DVC), which measures the RAC accuracy rate before being sent to CMS/CPI for approval
- If findings are approved, a "Notification of Improper Payment Letter" is issued identifying overpayment or underpayment and requesting payment for overpayment. Sponsors receiving an unfavorable finding have the opportunity to appeal.
The Part D RAC employs proprietary automated review software algorithms to review all PDEs and identify overpayments and underpayments. The RAC can conduct two types of reviews:
- Automated (data housed at CMS)
- Complex (additional data requested from the sponsor)
Part D RAC is guided by Medicare policies, regulations, and manual instructions when conducting all audits.
CMS/CPI determines the specific criteria on which the Part D RAC must review audit packages. To direct the RAC's review, CMS/CPI mandates review of files that fall within a particular year and contract for a particular plan. CMS/CPI further defines the audit scope to include the exact audit issue to be reviewed. Currently, the Part D RAC reviews for excluded providers and duplicate payments. Additional audit topics may be proposed to reflect results of studies that have been highlighted as problem areas by the U.S. Department of Health and Human Services (HHS), the HHS Office of the Inspector General and the U.S. Government Accountability Office.