Title of Regulation: 12VAC30-10. State Plan Under Title XIX of the Social Security Act Medical Assistance Program; General Provisions (adding 12VAC30-10-445).

Statutory Authority: § 32.1-325 of the Code of Virginia.

Effective Date: October 25, 2012.

Agency Contact: Brian McCormick, Regulatory Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-8856, FAX (804) 786-1680, or email brian.mccormick@dmas.virginia.gov.

Summary:

This action complies with the Centers for Medicare and Medicaid Services' (CMS) published letter from the State Medicaid Director informing states that, pursuant to § 6411 of the Affordable Care Act (Pub. L. 111-148), CMS requires states to establish a program under which the state contracts with one or more recovery audit contractors for the purpose of identifying underpayments and overpayments and recouping overpayments under the State Plan and under any waiver of the State Plan with respect to all services for which payment is made to any entity under the plan or waiver.

12VAC30-10-445. Recovery audit contractors.

A. The state has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State Plan and under any waiver of the State Plan.

B. The state/Medicaid agency has contracts of the type listed in § 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute.

C. The state will make payments to the RACs only from amounts recovered.

D. The state will make payments to the RACs on a contingent basis for collecting overpayments.

E. The state attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs as published in the Federal Register.

F. The payment methodology used to determine state payments to Medicaid RACs for the identification of underpayments will be based upon the percentage of the contingency fee.

G. The state has an adequate appeal process in place for entities to appeal any adverse determination made by the Medicaid RACs.

H. The state assures that the amounts expended by the state to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State Plan or a waiver of the plan.

I. The state assures that the recovered amounts will be subject to a state's quarterly expenditure estimates and funding of the state's share.

J. Efforts of the Medicaid RACs will be coordinated with other contractors or entities performing audits of entities receiving payments under the State Plan or waiver in the state, and/or state and federal law-enforcement entities and the CMS Medicaid Integrity Program.