WHY WE DID THIS STUDY: Recovery Audit Contractors (RAC) are designed to protect Medicare by identifying improper payments and referring potential fraud to the Centers for Medicare and Medicaid Services (CMS). Prior Government Accountability Office work has identified problems with CMS’s actions to address improper payment vulnerabilities, and prior Office of Inspector General (OIG) work has identified problems with CMS’s actions to address referrals of potential fraud. Further, OIG has identified vulnerabilities in CMS’s oversight of its contractors. Given the critical role of identifying improper payments, effective oversight of RAC performance is important.

HOW WE DID THIS STUDY: We collected RAC Data Warehouse (i.e., electronic database) files from CMS and data from RACs to determine their activities to identify improper payments and refer potential fraud in fiscal years (FYs) 2010 and 2011. We also collected data from CMS regarding activities to address vulnerabilities (i.e., improper payments exceeding $500,000 that result from a specific issue) and referrals of potential fraud. Finally, we collected RAC performance evaluations and performance evaluation metrics from CMS and determined the extent that RAC performance evaluations addressed these metrics. We also compared performance evaluation metrics to contract requirements to determine the extent that these metrics addressed contract requirements.

WHAT WE FOUND: In FYs 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments totaling $1.3 billion. CMS took corrective actions to address the majority of vulnerabilities it identified in FYs 2010 and 2011; however, it did not evaluate the effectiveness of these actions. As a result, high amounts of improper payment may continue. Additionally, CMS did not take action to address the six referrals of potential fraud that it received from RACs. Finally, CMS’s performance evaluations did not include metrics to evaluate RACs’ performance on all contract requirements. (Department of Health and Human Services, Office of Inspector General, 2013b, Executive summary, paras. 1–3)

For this case study address the following:

Summarize the information presented in this Case Study.

Compose a recommendation to CMS for complying with the findings of this study.

Please note: The case studies should be clearly labeled and combined into one document for submission. Each individual case study should meet the requirements listed above and should collectively be between 800 to 1,000 words in length, excluding the title and reference pages, and formatted according to APA guidelines as outlined in the Writing Center.

The Chapter 12 Case Study: Electronic Health Records and Chapter 14 Case Study: Recovery Audit Contractor and Fraud Reporting paper

Must be 800 to 1,000 words in length (double spaced and not including title and references pages) and formatted according to APA Style as outlined in the Writing Center’s APA Style (Links to an external site.) resource.

Must include a separate title page with the following:

oTitle of paper

oStudent’s name

oCourse name and number

oInstructor’s name

oDate submitted

Must include an introduction and conclusion paragraph. Your introduction paragraph needs to end with a clear thesis statement that indicates the purpose of your paper.

Must use at least four scholarly and/or credible sources in addition to the course text.

Must document any information used from sources in APA Style

Must include a separate references page that is formatted according to APA Style

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