Cononiah M. McCarthy, BBA, MPA

Reimbursement/RAC Analyst

Affiliation: The Schneider Regional Medical Center

It was the great English writer, Alan Moore who mentioned in his book V for Vendetta that “Authority, when first detecting chaos at its heels, will entertain the vilest schemes, to entertain its orderly façade.” In our society, government is the authority. The strength of the Government is evident within the areas of education, finance, commerce and of course our favorite; healthcare. Since healthcare is my favorite industry I think it is only fitting that we explore the authorities within this industry. These authorities operate like gangsters that expedite a façade of order in the healthcare sector, while executing the vilest schemes. The biggest culpable authorities are the Recovery Audit Contractors. Or you may prefer the more accurate description I branded; the Recover at All Cost groups.

The RACs were established as a measure to find and recoup incorrect Medicare payments, which was ideally an overall government initiative to locate and cut wastage. As a result, Congress established the national Recovery Audit program under section 302 of the Tax Relief and Health Care Act of 2006. Now seven years later, if you survey the nation the response on the impact of the RAC’s is definitely not in unanimity. However, the one group of the healthcare industry that has echoed in unison the impact of the RACs is the healthcare providing institutions. The healthcare providers feel harassed and burdened by the RACs unreasonable requests and audits, according to the American Hospital Association (Facts about H.R. 1250 and S. 1012,2013). (source). Without a doubt, the burdens on the hospitals in the US Mainland are also shared by the healthcare providers in the US territory states in the Caribbean, specifically the US Virgin Islands. By utilizing the US Virgin Islands as a case example, one will be able to construe the extent of the scheming behaviors by the (RACs) Recover at All Cost groups.

Overpayment to Healthcare Providers

The US Virgin Islands, which falls under Region C, received their first RAC letter in November, 2011. From that date to present, the content and process of the RAC letters have changed.  Keep in mind, the change was not beneficial. The RAC letters abated from being detailed descriptions of errors to ambiguous notes alluding that a recoupment should be done. I can even delve further by revealing that when customer representatives are contacted about an ambiguous RAC letter, the most information the representatives are knowledgeable to give is one that says the overpayment is for a RAC take back. If you persist to ask why the overpayment was a RAC recoupment another ambiguous response would be given. The RACs failure to produce concrete premises clearly violates its (SOW) Statement Of Work. Further, it is The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, that lucidly states in section 935, that “when a Medicare contractor audits a provider or supplier, the contractor shall give the provider or supplier a full review and explanation of the findings of the audit in a manner that is understandable to the provider or supplier and permits the development of an appropriate corrective action plan” ( Statement of Work for the Recovery Audit Program, 2011). That is a clear example of the healthcare gangster behavior of the Recover at All Cost groups.

Communication Barrier

The trickeries for the RACs in Region C expand beyond ambiguous demand letters. The US Virgin Islands experienced one case whereby the recovery auditor issued a demand letter in Spanish to an English healthcare providing facility. This issue has occurred on several occasions. It is evident that the recovery auditors are utilizing a tactic that will ensure the provider is delayed in responding to the demand letter. In that way, the provider would be deterred to attempt a strong appeal. Consequently, the RAC would be successful at their recoupment then capitalize on a contingency fee.

Given the repetition of these cases in the US Virgin Islands, my question is how many other providers have been hit with a similar RAC tactic? The recovery auditors must be cognizant of the language barriers that may be present amongst the providers they serve. Moreover, any barrier that sets providers uniquely apart should be taken into consideration at all times by the RAC. The purpose should always be to ensure that every provider receives the fair chance of defending or correcting their role in a Medicare claim. But of course, when you operate like a Recover at All Cost group, why would you care about parity to the healthcare providers?

If you thought that was the end of the RAC trickeries in Region C, think once more. The next chicanery by the Recover at All Cost Groups is the most amusing and novel one for providers in the US Virgin Islands.

Double Payment

The RAC for Region C issued a favorable appeal letter, then subsequently informed the provider that the monies issued after the favorable appeal should not have been issued. The RAC claimed that the monies were not initially recouped from the provider; therefore the provider received a double payment. When that notice was received in the US Virgin Islands, it was counted as another attempt by the RAC to recover monies treacherously. It was evident that the provider was absolutely not in error. The provider’s accounting receipts revealed a recoupment on one date then a subsequent payment on another date. Again, I would ask, how many other providers have been hit with the identical RAC tactic?

The US Virgin Islands is the smallest territory within Region C, however, they have not been shown mercy by the Recover at All Cost Groups. The US Virgin Islands still bears the burden of administrative costs that so many national providers bear as a result of the RACs activities. The burdens get heavier when small territory providers have to fight against big scheming activities that evidently violate the RACs Statement of Work (SOW).

Are you convinced that RACs have been rightfully labeled as Recover at All Cost Groups? In no way should the RACs be operating like Recover At All Cost Groups. Congress must now understand that contractors who work for a contingency fee will never produce fair results. Frankly, the contractors will always expedite scheming activities that will produce results that profit them as an entity. It is therefore pertinent that healthcare providers around the nation, regardless of size, support organizations such as the American Hospital Association that earnestly lobbies for the interest of the burdened providers.

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