195.933: Extrapolation by Medicare Recovery Audit Contractors (RACs)
MSSNY will urge the American Medical Association to petition the Centers for Medicare and Medicaid Services (CMS) to amend CMS’s rules governing the use of extrapolation in the Recovery Audit Contractor (RAC) audit process, so that the amended CMS rules conform to Section 1893 of the Social Security Act – Subsection (f) (3) – Limitation on Use of Extrapolation. MSSNY will insist that the amended rules state that when a RAC initially contacts a physician, the RAC is not permitted to use extrapolation to determine overpayment amounts to be recovered from that physician by recoupment, offset, or otherwise, unless (as per Section 1893 of the Social Security Act) the Secretary of Health and Human Services has already determined, before the RAC audit, either that (a) previous, routine pre– or post–payment audits of the physician’s claims by the Medicare Administrative Contractor have found a sustained or high level of previous payment errors; or that (b) documented educational intervention has failed to correct those payment errors. (HOD 2013-251; Reaffirmed HOD 2023)
