Recovery audit program

Preventing and identifying improper payments through recovery audits

The federal deficit is approaching $1 trillion, states are experiencing the largest budget gaps and unemployment rates in decades, and government-sponsored healthcare programs continue to grow in demand. The Patient Protection and Affordable Care Act (ACA) increases the number of citizens eligible for state Medicaid benefits and it is estimated that another 16-20 million will be enrolled in Medicaid beginning in 2014. Now more than ever, there is a critical need to protect the integrity of the nation's largest healthcare programs – Medicare and Medicaid. In fiscal year 2010 alone, these programs erroneously paid $56.8 billion in medical claims – accounting for more than half of the federal government's total improper payments.

Recovery Audit Contractor (RAC) program expansion

The 2006 Tax Relief and Health Care Act required the Centers for Medicare and Medicaid Services (CMS) to contract with Recovery Audit Contractors (RACs) to handle recovery of improper payments for Medicare Fee for Service. Nearly $1 billion was recovered during the first phase of the RAC program and CMS anticipates significantly higher results for the permanent RAC program that began in 2009. To build on RAC successes, ACA has expanded the program to include all State Medicaid programs as well as Medicare Parts C and D. The government's renewed emphasis, including the Improper Payments Elimination and Recovery Act in 2010, also paves the way for more RAC-type programs.

CGI recovery audit services and solutions

CGI is one of the four permanent Medicare RAC firms, covering 7 states and 8.5 million beneficiaries in Region B. As a leader in healthcare claims auditing and recovery for nearly 20 years, CGI has the experience, best practices and systems to help State Medicaid agencies and Medicare Parts C and D plans accelerate RAC start-up programs. Our experience includes:

  • Performing reviews and audits on behalf of Medicaid, Medicare and private industry
  • Breadth and depth of knowledge of a variety of payment methodologies, state and federal regulations and medical policies and contracts unique to each payer
  • Proven claims audit and recovery services, powered by CGI's Customized Audit System (CAS), that have been used to audit approximately 30 million covered lives by payers ranging in size from 60,000 to 9 million members
  • Track record of success in identifying more than $1 billion in cost savings and recoveries for public and private healthcare payers.