Recovery Audit Contractor Services

The Vendor is required to provide the recovery audit contractor (RAC) program is to reduce improper payments through the efficient detection and collection of overpayments, the identification of underpayments, the reporting of suspected fraudulent activities, and the identification of actions that will prevent future improper payments.
- Provide all resources necessary to perform audits of state medicaid providers.
- Identify all improper payments made to authority providers including payments made to the wrong provider, payments made for the wrong services, and payments made without sufficient documentation; however, contractor will only be reimbursed for the proper identification of overpayments and underpayments.
- Request and review financial documents and healthcare records from providers to identify any improper payments.
- Request and review financial documents from providers to identify no refunded credit balances.
- Develop an audit process, which must be approved by authority, and addresses the following requirements, at a minimum:
• Use of qualified professionals to perform audits of state medicaid providers;
• Identifies, discloses, and mitigates any conflicts of interest or impairments to objectivity;
• Time frame for completing reviews that is in alignment;
• Adequate documentation for every claim reviewed and every improper payment identified. This includes a description of all processes utilized by the RAC in the determination of audit results;
• Authority approval of all provider correspondence templates;
• Authority approval prior to issuance of all actual provider correspondence, including but not limited to:
1) Record request letters and lists;
2) Preliminary finding notices and preliminary findings;
3) Response to provider disputes;
4) Notice of improper payment and final findings.
• Authority approval of any modifications to language in any provider correspondence previously approved by authority;
• Submission to authority of any review or audit findings with claim details prior to issuance to providers;
• Detection of improper payment trends and process for reporting to authority;
• Quality review of findings prior to issuance to provider; and
• A provider informal dispute resolution process to include a medical director review of all upheld findings.
- Contract Period/Term: 1 year
- Pre-Proposal Conference/ Questions Date: March 3, 2025