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TO: All Medicaid Providers
RE: Medicaid Recovery Audit
Contractor (RAC) Audits
Mandatory provisions
of the Affordable Care Act require the Alabama Medicaid Agency (Medicaid) to
select and provide oversight for a Medicaid Recovery Audit Contractor (RAC) to
perform provider audits. Alivia Analytics, LLC (Alivia) was selected to be Medicaid’s
RAC effective October 1, 2024. 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 Alivia staff to
include a medical director, certified professional coders, and experienced
clinicians. Audits will be conducted by Alivia 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 Medicaid and/or national standards. Following the high-level claims analysis, Alivia may expand
its review by requesting clinical records and/or other documents in accordance
with state and federal regulations.
Alivia 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 Jamie Cousins, RAC Program Manager, at (334)
353-8025 or jamie.cousins@medicaid.alabama.gov or Yulonda Carter,
Recipient Review Associate Director, at (334) 242-5161 or yulonda.carter@medicaid.alabama.gov.
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