(Independent Review Entity) handles the first level of appeals from plan sponsors challenging RAC findings.
A list of audit issues that the RAC is required to review during a given year.
A review completed based upon available prescription drug event (PDE) records where approved processes are considered to be acceptable without further review of prescription or other documentation.
The Center for Program Integrity (CPI)
CPI serves as the CMS focal point for all national and state-wide program integrity, fraud and abuse issues in the Medicare and Medicaid programs, and the Children's Health Insurance Program (CHIP). Specifically, the Division of Plan Oversight and Accountability (DPOA) is the division within the CMS/CPI Investigations & Audits Group responsible for ensuring program integrity for Parts C and D, and oversee Medicare Part D RAC.
Centers for Medicare and Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) permanently implemented the FFS RAC Program on a nationwide basis in October 2009. The Affordable Care Act, section 6411(b), added section 1893(h)(9) to the Act, which expanded the use of RACs to include the Medicare Advantage (Part C) and prescription drug (Part D) programs. CMS’ Center for Program Integrity (CPI) serves as the focal point for all national and statewide Medicare, Medicaid, and Child Health Insurance Program (CHIP) efforts for preventing and reducing fraud, waste and abuse (FWA).
A review determined to require response to a Request for Information (RFI) from the plan sponsor to adequately validate compliance with CMS policy and applicable laws. RFIs may include requests for prescriptions, prior authorizations or other documentation as required to address the specific issue under audit.
Data Validation Contractor (DVC)
Measures the accuracy rate of the RAC. The DVC validates the improper payments identified by the RAC to determine if they are accurate and will review and approve/disapprove improper payment referrals.
An individual or entity that has been excluded from participation in Medicare, Medicaid, and all other Federal health care programs.
Items and services furnished, ordered, or prescribed by an excluded individual or entity will not be reimbursed under Medicare, Medicaid, and all other Federal health care programs until the individual or entity is reinstated by the Office of Inspector General (OIG).
Improper Payment Review Package (IPRP)
An improper payment file and the supporting documentation for a particular audit issue by contract and year.
National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)
The purpose of the NBI MEDIC is to detect and prevent fraud, waste, and abuse in the Part C (Medicare Advantage) and Part D (Prescription Drug Coverage) programs on a national level. Health Integrity is the Medicare Part C and Part D program integrity contractor for the Centers for Medicare & Medicaid Services (CMS).
New Audit Issue Review Package (NAIRP)
The package of proposed audit issues and includes a sample of Prescription Drug Event (PDE) records for a specified contract year, a new audit issue, an estimate of improper payment amount and the audit methodology.
Notification of Improper Payment (NIP)
The NIP indicates the audit issue being reviewed, the applicable laws, the amount of the overpayment, how it was calculated and the plan sponsor’s appeal rights. The Improper Payment Exception Report, an encrypted file sent with the NIP, will include the PDE records associated with the identified improper payment.
Payment Recovery Information System (PRIS)
PRIS houses referrals made to CMS/CPI after improper payments are identified. The Part D RAC and DVC review the PDEs and their accompanying support submitted into PRIS. Then, the DVC either confirms or rejects the Part D RAC findings, and updates the IPRP in PRIS.
Prescription Drug Event Records (PDEs)
Summary records submitted every time a beneficiary fills a prescription under Medicare Part D. The PDE data are not the same as individual drug claim transactions, but are summary extracts using CMS-defined standard fields.
Recovery Audit Contractor (RAC)
Responsible for reducing Medicare improper payments through the efficient detection of overpayments, underpayments, and assists with the identification of vulnerabilities that will prevent future improper payments. Originally implemented for FFS Medicare, the ACA (Section 6411(b) expands the original RAC Program to Medicare Parts C and D.
Part D Plan Sponsors (plan sponsors)
Private organizations that contract with CMS to administer Medicare Parts C and/or D benefits and may offer several different types of Medicare Part C and/or Part D plans. Plan sponsors include, but are not limited to, Medicare Advantage – Prescription Drug Plans (MA-PDPs), and Prescription Drug Plans (PDPs).