The tone of many such programs was set by presenter Bill Mathias of Ober Kaler, attorneys at law, who started his presentation with a quote from Chief Judge Ervin of the U.S. Court of Appeals for the Fourth Circuit.  Ervin was quoted as having stated “there can be no doubt but that the statutes and provisions in question involving the financing of Medicare and Medicaid are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity herein demanded with dread, for not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of matters addressed merely a passing phase.”


Speakers presented a variety of topics ranging from overviews of the various oversight initiatives (RAC, MIC, MAC, ZPIC) to the legal issues associated with appeals and OIG investigations. Revealed was the fact that the aforementioned contractors and agencies are mining claims databases in order to identify billing practices that may indicate improper billing and/or reimbursement. While the RACs have restrictions on the number of records they can request or audit targets that they may pursue (a RAC must have prior approval from CMS), such restrictions do not exist for other investigative bodies.


Several presentations focused on the emerging role of the Medicaid Integrity Program and its review organizations: Medicaid Integrity Contractors, or MICs. This program currently is funded at a rate of $75 million per year. Starting in 2011, however, this amount will be increased annually by the Consumer Price Index percentage. Currently there are 854 audits being conducted in 31 states.


In addition to the growing federal presence in review of Medicaid claims, there also is a growing degree of state oversight. New York has the largest such program, with 600 employees. The Office of Medicaid Integrity Group (OMIG) has a work plan that is modeled after the federal OIG work plan.  Other states are creating Offices of Medicaid Integrity Groups as well.


As if that wasn’t enough oversight, the newly passed Patient Protection and Affordable Care Act (PPACA) requires states to sign contracts with Recovery Audit Contractors (RACs) by the end of 2010. It remains to be seen exactly what role the RACs will play in the oversight of Medicaid programs.


All presenters urged providers to be prepared for an increase in oversight activity by clearly identifying who will coordinate responses, being aware of the various deadlines for providing documentation, knowing your legal rights and filing disagreements and appeals as appropriate.


About the Author


Cheryl E. Servais, MPH, RHIA, has more than 25 years of experience in health information management. In her position at Precyse Solutions, Ms. Servais’ responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the executive and board levels and takes an active role in professional organizations.


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“The Medicaid Integrity Program”, Joanne Erde, Esq; Duane Morris, LLP April 19, 2010


“Medicaid Fraud Enforcement”, Jack Wenik, Esq; Sills Cummis & Gross, P.C., April 19, 2010


“Involuntary Investigations & Voluntary Disclosures: A Real World Perspective”, Bill Mathias, Ober/Kaler, attorneys at law; April 20, 2010

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