Connolly Healthcare, a permanent Recovery Audit Contractor (RAC) for the Centers for Medicare and Medicaid Services, has signed a five-year license agreement with Milliman Care Guidelines.
Connolly will be reviewing Medicare claims in 15 states – West Virginia, Virginia, North Carolina, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana, Tennessee, Arkansas, Texas, Oklahoma, New Mexico and Colorado – plus the territories of Puerto Rico and the U.S. Virgin Islands.
Under federal law, RACs review claims for compliance with CMS reimbursement policies and identify both underpayments and overpayments. According to CMS, the RAC program will roll out nationwide by Jan. 1, 2010.
Connolly will use all annually updated, evidence-based Care Guidelines products – Ambulatory Care, Inpatient and Surgical Care, General Recovery Guidelines, Recovery Facility Care, Home Care, Chronic Care Guidelines, and Behavioral Health Guidelines.
CMS does not mandate or endorse the use of any specific screening product for medical reviews.
"The breadth and detail of the Care Guidelines enable informed and consistent clinical decisions for the best possible care throughout the entire care continuum," said Scott Harris, senior vice president of sales and marketing for Milliman Care Guidelines. "Having access to our evidence-based clinical tools enables quality and audit organizations to effectively manage their review processes and initiatives to improve the care provided for Medicare beneficiaries."
Harris said the Care Guidelines incorporate detailed quality measures from the Hospital Quality Alliance (CMS Core Measures) and other national standards-setting groups. Each guideline topic outlines key issues and provides details on clinical interventions to improve patient outcomes.
Connolly Healthcare is a division of global recovery audit firm Connolly. The Wilton, Conn.-based firm assists clients in the industries of healthcare, retail, commercial and government in recovering erroneous payments to suppliers, vendors and providers.