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Monday, October 20, 2014
  Clinical Accuracy Spoken Here  

UM: Regulations, Guidelines
and Laws. Why?

Federal and state regulations set standards to improve the efficiency, effectiveness, safety, and confidentiality of the health system

Regulatory guidelines or rules are established to stipulate how a federal or state law is to be implemented.

Laws, also called acts, create the "What", while regulations describe the "Hows".

[Reference: UM, Module A, Standards and Regulations]

  Excellence in Case Mgmt  

UM: Recovery Audit
Contractors (RAC)

The Tax Relief and Health Care Act (TRHCA) of 2006 made permanent the Medicare Recovery Audit Contractor (RAC) program to identify improper Medicare payments in all 50 states. This included both:

  • Overpayments
  • Underpayments

As required by The Tax Relief and Health Care Act of 2006, the permanent RAC program is now implemented in all 50 states.

Of the $992.7 million in improper overpayments identified during the RAC demonstration project, 85% were collected from inpatient hospital providers.

[Reference: UM, Module A, Standards and Regulations]

  Improving Patient Care...  

UM: Zone Program Integrity Contractors (ZPIC)

When Congress passed the Healthcare Portability and Accountability Act (HIPAA) in 1996, it established the Medicare Integrity Program which authorized CMS to contract with program safeguard contractors (PSCs) to identify fraud and improper billing.

In 2008, CMS began consolidating the functions of the PSCs and the Medicare prescription drug integrity contractors into zone program integrity contractors (ZPIC) to look at billing trends and patterns, focusing on providers whose billings for Medicare services are higher than other providers in the community.

Cases of potential fraud are referred to the Office of the Inspector General (OIG) for possible initiation of legal action.

[Reference: UM, Module A, Standards and Regulations]


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