Nebraska Medicaid Program
Recovery Audit Contractors (RAC)
Section 6411 of the Patient Protection and Affordability Care Act of 2010 requires states to contract with a Recovery Audit Contractor (RAC) to identify and recover overpayments and underpayments. The complete final rule may be viewed at http://www.gpo.gov/fdsys/pkg/FR-2011-09-16/pdf/2011-23695.pdf
HMS (Health Management Systems, Inc.) has been contracted with Nebraska Department of Health and Human Services (DHHS) as the Nebraska Medicaid Recovery Audit Contractor (RAC). HMS is authorized to audit provider claims and associated medical and financial records. The Nebraska Department of Health and Human Services’ (DHHS) Division of Medicaid and Long-Term Care (MLTC) will oversee the Medicaid RAC program for the State of Nebraska.
HMS is responsible for providing Nebraska Medicaid RAC services. All audit algorithms go through a Nebraska specific analysis and must be approved by Nebraska Medicaid and Long-Term Care. HMS will audit Nebraska Medicaid paid claims in three ways:
Automated Reviews Analysis of improper payments that can be determined from claim data elements, and well established policy and rules.
Semi-Automated Reviews Billing and reimbursement analysis and improper payments can be determined by a combination of claim data elements with well established policy and rules and review of documentation by qualified staff.
Complex Reviews Billing and reimbursement analysis that cannot be automatically validated and require medical documentation review conducted by qualified staff.
Upon completion of HMS’ review of the supporting documentation, providers will be notified by Nebraska Medicaid of the outcome of the review. In addition to standard appeal rights providers disagreeing with HMS' findings will have an opportunity to request a reconsideration of the findings with HMS. Detailed instructions will be communicated to the providers in the audit results letter. RAC Administrative Appeal Instructions and RAC Appeal Cover Sheet.