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Recovery Audit Contractor

The Recovery Audit Contractor (RAC) program was implemented by the Mississippi Division of Medicaid (DOM) to conduct post-pay audits of claims in order to correct improper payments. The RAC Program was implemented to protect the Medicaid Trust Fund from fraud, abuse, and waste. Improper payments are classified as overpayments and underpayments.

Current Audit Concepts for the Recovery Audit Program – July 25, 2016

Inpatient Diagnosis Related Group (DRG) Review
Validation of the diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported on claims billed are correct for Inpatient DRG Claims

Types of Inpatient DRG Reviews:

  • APR-DRG Validation
  • Newborn Conditions
  • Rehabilitation Stays
  • 96-Hour Mechanical Vent

RAC Probe Reviews
RAC probes are mini-reviews conducted to identify high-risk areas that merit a full-scale audit. Upon completion of the probe reviews, the RAC submits the issue(s) to the DOM for review and approval before audit work begins. There are no current probe reviews.

Abrasion Limits and Calculations

Effective July 1, 2014, abrasion limits and calculations are as follows:

  • A provider is defined as those having the same tax ID and same first three digits of the zip code.
  • Extremely small providers may be excluded from audit; the limit will vary by provider type and is based upon total claims volume submitted to Mississippi DOM in the previous calendar year.
  • Record requests will be sent out once every 72 days. No provider will receive a record request more frequently than once every 72 days, i.e., per wave.
  • The volume of records that can be requested in each wave will be calculated as follows:
    • – Two and a half percent (2.5%) of the volume of claims submitted by the provider in the previous calendar year divided by five waves per year.
      • – If the resulting number is less than 20, the limit will be raised to 20.
      • – If the resulting number is greater than 200, the limit will be capped at 200.
  • To the extent that multiple claims for the same patient are selected in a wave, all claims for the same patient will be listed on the same correspondence (ADR, demand letter, etc.)

Recovery Audit Contractor Compliance

DOM utilizes office staff, contracted audit entities or combination of both to conduct auditing and monitoring reviews of Medicaid providers. The RAC is contracted by the DOM as an audit entity. Providers should follow the guidelines in reference to audits as stated in the Administrative Code when receiving correspondence from the RAC. Providers receive Medical Record Request letters from the RAC which initiates the beginning of an audit.

Providers who do not comply with this request are subject to technical denials. Technical denials occur after medical records have been requested and providers do not comply by sending in the requested documentation. The Administrative Code Title 23, Part 304, Audit/Monitoring Review Overview states, if a provider fails to participate or comply with the Division of Medicaid’s audit process or unduly delays the audit process, the Division of Medicaid considers the provider’s actions or lack thereof, as abandonment of the audit. If the DOM suspects a provider of fraud, abusive practice, audit abandonment, or present a risk of imminent danger to clients, the DOM may take one or more of the actions listed below:

  1. Immediately issue a final report
  2. Terminate the provider’s agreement with Medicaid
  3. Issue a subpoena for the provider’s records
  4. Refer the provider to the appropriate prosecuting authority

Resubmitting RAC Claims That Are Subject to Partial Denials and Have Passed Timely Filing
Demand letters are mailed to notify providers of overpayments made by the Division of Medicaid. Providers are responsible for submitting Adjustment/Void Request Forms in instances when a partial overpayment has been identified. Partial overpayments occur when a Transaction Control Number (TCN) has multiple line items and not all line items were billed in error. Adjustment/Void Request Forms must be submitted within 30 days of receipt of the demand letter.

Submit along with the Adjustment/Void form the resubmitted claim on the appropriate form, the CMS1500 or the UB-04, to the Division of Medicaid, Office of Program Integrity. These claims are subject to timely filing and will be overridden. Please be sure to confirm that the Voided TCN has been included in the correct field of the resubmitted claim.

Recovery Audit Contractors Resources

RAC Contacts

If you must make any changes regarding mailing address or point of contact information, contact the Division of Medicaid, Office of Program Integrity:

Toll-free: 800-880-5920
Phone: 601-576-4162
Fax: 601-576-4161

Mississippi Division of Medicaid
Office of Program Integrity
Attn: Kameron M. Harris
Walter Sillers Building
550 High Street, Suite 1000
Jackson, MS 39201

Providers can also submit inquiries, complaints and other communications in regards to the Mississippi RAC Program to the Division of Medicaid, Office of Program Integrity by email at MSRAC@medicaid.ms.gov.