Case Study: Recovery Audit Contractor (RAC) Demonstration project

Background: The Center for Medicare and Medicaid Services’ (CMS) ran a three-year, three-state Recovery Audit Contractor (RAC) Demonstration project.  PRGX was selected to provide Recovery Audit services for the demonstration, and developed specialized expertise in identifying waste and overspending.

PRGX Results: As part of the CMS demonstration project, PRGX recovered $318 million for CMS from providers in California alone.

Overall, the government recouped about one billion dollars from the three-state demonstration program and the results of the pilot were so compelling that Congress passed a Bill to make the program permanent.

The Recovery Audit Contractor (RAC) program is now being rolled out nationwide.  PRGX is working on rolling out the program in 11 states.

Case Study: State Medicaid Overpayment Audit

Background: Legislature established a requirement for a centralized overpayment recovery audit program to be established.  PRGX tailored the program to meet the needs of the state by working with all parties in defining audit calendar years, communication to providers and collaboration in the development of audit concepts.

PRGX Results: PRGX implemented a tailored/focused program on inpatient hospital records resulting in thousands of requested medical records.  After careful review of the medical records by qualified professionals the project resulted in a 38% error rate representing an average overpayment per claim value of $4,500.

Example: A Provider billed for inpatient services on a 35-year old male with a non-healing necrotic ulcer of the thigh.  Using a Versa™ jet debrider, the physician performed “debridement” of the wound.  The Provider billed for an excisional debridement of the skin resulting in $10,000 reimbursement to the Hospital.  After careful chart review, the auditor confirmed that a Versa™ jet debrider vacuums tissue fragments that are dislodged after a jet stream of solution is passed over it.  No excisional debridement was performed and coding changes were applied resulting in an identification of $5,000 of overpayment dollars.

PRGX remains committed to our client in communicating these outcomes to the providers, assisting with education and any follow through associated with appeals related to our findings.

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