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Medicaid RAC Considerations

Finding your ideal Medicaid RAC partner

What are the qualifications of the ideal Medicaid RAC partner? Only you can decide. In developing your Medicaid RAC solution, be sure to look for a partner with proven experience in delivering mission-critical healthcare solutions to Medicaid agencies that reduce costs, advance the quality of care, and promote public health.

The ideal partner will be able to deliver a solution designed to support the identification, validation, audit, billing, and recovery of claims.

You should look for:

  • Accurate determinations
  • Effective provider outreach and education
  • Rapid implementation and exceptional results
  • Low rate of overturn for appealed claims
  • Minimal disruption or administrative burden on client staff and resources
  • Outstanding customer service
  • Experience working with Medicaid claims data and regulations

Key indicators of an effective Medicaid RAC partner

Consider these five key indicators when evaluating a vendor’s experience and capabilities to determine if they will serve as an effective partner:

  1. The right experience and credentials
    • An exceptional partner offers competent and proven staffing models that challenge the norm.
    • Qualified professional staff should be trained and supported by experienced physicians.
    • Physician oversight and involvement, combined with solid training and the use of physician-approved guidelines, minimizes the number of determinations that require physician review.
    • Registered Nurses and/or Certified Coders to conduct clinical claims audits to maximize the identification of improper payments. Following GAAS and GAGAS regulations may only be beneficial when performing financial audits.
    • The ideal partner will have processes in place for ensuring seamless and timely system and program upgrades
    • Seek a partner who brings deep experience working with healthcare data
  2. Effective strategies and processes to maximize recoveries
    • Data Mining
    • Document Management and Control
    • Audit and Review Processes
    • Quality Assurance Plan
    • Recovery Processes
    • Appeals Processes
    • Reporting Processes
  3. Superior business application technology with full infrastructure management capabilities
    • Transparent, online access to activities and results, enabling a “single view” of vendor projects
    • Ability to intake claims and encounter data, program eligibility, provider, reference, and other claims system data
    • Secure file acceptance and file transmission capabilities
      Ability to track service levels and usage to ensure that programs are not incurring costs for inappropriate care and are not paying for fraudulent services
    • Claim tracking capabilities and exclusion logic to ensure non-duplication of recovery efforts
    • A sophisticated case management system that houses all aspects of each individual case
    • Document imaging software that can image large amounts of documentation in support of a paperless environment
  4. Effective client and provider communication
    • Understanding how to build effective relationships with providers is critical to minimize provider abrasion and implement educational programs to stop issues at the root cause
    • Demonstrated ability to identify and document initial and ongoing project requirements and deliverables
    • Effective project management methodology to ensure review timelines are met, recovery goals are achieved, and open channels of communication with all stakeholders are maintained
  5. Ability to deliver results
    • Select a partner with proven results in exceeding performance requirements:
    • Validate the vendor’s record of success in performing reviews within established timeframes
    • Evaluate the vendor’s ability to meet the deadlines relating to the delivery of timely, accurate reports describing the number of audits conducted, amount of recoveries, and other key statistics
    • Set performance standards for the vendor such as review timelines, overturned appeals rate, accuracy reporting, and invoicing accuracy. Review the vendor’s ability to provide complete and timely responses to provider and/or other stakeholder inquiries and/or complaints Such as reviewing the vendor’s hold times, dropped calls, results of satisfaction surveys etc.
    • Ensure the vendor has adequate financial resources to support multiple, ongoing engagements in a contingency fee-based contract model