"Providers need to prepare to manage the process and be intimately familiar with the many regulations, guidance, and interpretations pertaining to admission review," he says. "With any of the healthcare auditing entities, it's not enough to simply reach the correct medical necessity answer, but that answer must be reached through the implementation of a daily compliant review process. You want to have a process that is so ironclad that auditors—particularly contingency auditors—have nothing to find."
Sara Kay Wheeler, partner at King & Spaulding LLP in Atlanta, concurs it's crucial for providers to know the differences when it comes to Medicaid.
"The partnership between the states and CMS in administering the Medicaid program makes the program so different that while there may be some general lessons to be learned from the Medicare RAC program, the influence of state law and the intricacies of each state's Medicaid program will make these Medicaid RACs function very differently," she says. "When you think about how the country is carved up by the Medicare RACs, there are only four RAC contractors covering the entire nation; but with Medicaid RACs, states can contract with one or more entities, and there may be reason for states to engage companies that are the most knowledgeable with the way the state's reimbursement rules actually work."