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Recovery Audit Contractor (RAC) Audits

Mandatory provisions of the Affordable Care Act require the Alabama Medicaid Agency to select and provide oversight for a Medicaid Recovery Audit Contractor (RAC) to perform provider audits.  Goold Health Systems (GHS), a Maine-based firm, was selected to be Alabama Medicaid’s Recovery Audit Contractor (RAC) effective January 1, 2013.

The RAC program is designed to improve payment accuracy by identifying under and overpayments in Medicaid.  The Medicaid RAC program is a separate program from the Medicare RAC which is overseen by the Centers for Medicare and Medicaid Services.

Reviews will be conducted by GHS staff to include full time medical directors, pharmacists, certified professional coders, and experienced clinicians.  Audits will be conducted by GHS using a “top down” approach where data analysis, through data mining, is applied against the universe of paid claims to identify patterns of utilization or billing which look atypical based on Alabama Medicaid and/or national standards. Following the high-level claims analysis, GHS may expand its review by requesting clinical records and/or other documents in accordance with state and federal regulations. 

GHS has been informed of the critical role that all providers play in a successful Medicaid program and requires that auditors be professional, objective, and consistent in performing all required audits/reviews. 

Providers are reminded that the Alabama Administrative Code, the Provider Manual and their Provider Agreements require compliance with requests for medical records for Medicaid program audits.

Questions regarding the audits should be directed to Yulonda Morris, RAC Program Manager, at (334) 242-5161 or yulonda.morris@medicaid.alabama.gov or Patricia Jones, Recipient Review Associate Director, at (334) 242-5609 or patricia.jones@medicaid.alabama.gov.

RAC Review Results by Provider Type - Updated 9-30-16