RYAN HENRY: Discontinuing Government Programs: A Case Study of a Contract Recovery Audit Program. An analysis of Recovery Audit Contracting, a program designed to prevent fraud, waste and abuse in the Medicare and Medicaid systems, shows that audit programs are inherently more prone to disruption than other types of government programs. The gradual development of the federal government has resulted in an enormous number of government programs and agencies.
Government programs are established to solve a problem or to meet a need in society that the market cannot at a particular time. He identifies seven factors that contribute to the longevity of government programs and helps explain why they often seem immortal. The vast majority of government programs contribute to their own success by becoming active participants in the policy process and advocating.
Simply by solving a problem that the marketplace cannot get government programs to gain popular support and become difficult to uninstall. Although government programs are designed for sustainability, program termination is an important part of the policy-making process.
Termination Factors
Each of these aspects plays an important role in the longevity of a government program (Lewis, 2002, p. 95). Governments will cut unnecessary programs during tough economic times to redirect funding to programs essential to the functioning of the nation (Daniel, 1997). Lewis attributes this to the way the president shifts government responsibilities across agencies to prepare for mobilization (Lewis, 2002, p. 97).
New presidents often reorganize the bureaucracy and government programs to gain power at the beginning of their term of office (Lewis, 2002, p. 95). The termination and reinstatement of the B-1 bomber program is a prime example of the president's power to dictate the life of a program. When President Jimmy Carter, a Democrat, took office, one of his first steps was to halt development of the B-1 bomber.
Unified governments, where the same political party holds the presidency and Congress, are the most dangerous for government programs, terminating about twice as many programs as a divided government. External factors such as the political environment also results in the termination of government programs.
History of the Recovery Audit Contracting Program
The Medicare and Medicaid programs have expanded since the 1960s, so the structure of the program has changed to accommodate the growing number of beneficiaries. Medicaid and Medicare are two of the largest and most important programs in the country. In 2014, Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services states that the programs provide insurance to more than 102 million individuals, or almost 1 in 3 Americans (Tavenner, 2014).
Medicare and Medicaid are two of the top three programs with the most improper payments (Health & Human Services, 2008, p. 7). The Recovery Audit Contracting (RAC) program is designed to find and correct improper payments in order to protect the integrity of the Medicare Trust Fund. The RAC program is designed to calculate improper payment rates and identify areas in the health care system that are particularly vulnerable to payment errors.
This means that if the hospital was paid more than it should have been, the RAC reimbursed. If the hospital was underpaid, the RAC would ensure proper reimbursement for services (Health & Human Services, 2008, p. 3). For example, an auditor could use the program to find two of the same surgical procedures for the same patient on the same day.
In a complex review, the RAC requests medical records from the billing computer to conduct an in-depth review. The audit of only 0.3% of the 4 billion claims made in the 3-year period more than corrected the RACs. About 95% of the improper claims found by the protest overbilled Medicare, so the RAC recovered the improper.
CMS reviewed the RAC demonstration favorably in 2008 and presented a nationwide implementation program with several modifications. Given these changes, Congress included Section 302 of The Tax Relief and Healthcare Act of 2006 and required the RAC program to be implemented nationwide by 2010 (Centers for Medicare & Medicaid Services, 2008, p. 2). The report demonstrates the success of the expanded, nationwide RAC program and provides an in-depth look at the traditional RAC program and.
Percentage of Improper Payments Made Under the Medicare Fee-for-Service Program
Termination of the Recovery Audit Contracting Program
In 2003, some of the most influential politicians in the Bush administration pushed to install the RAC program. As of 2003, all of these men have retired from Congress and no longer have significant enough political influence to prevent the RAC program from being terminated. While citizens benefit from Medicare and Medicaid services, they are not directly affected by the RAC program.
Instead, the controversy surrounding the program makes it highly unlikely that CMS will support the RAC program. Finally, the RAC program does not enjoy the endorsement of healthcare or auditing trade and professional associations. The RAC program returns millions of dollars of wrongfully distributed money to the Medicare and Medicaid trust funds in an effort to protect the program from fraud, waste, and abuse.
According to Kaufman, the RAC program lacks most of the factors that promote longevity because it lacks a strong relationship with congress, outside entities, and professional associations. Analyzed using Kaufman's method, the RAC program should have a long lifespan without much fear of termination. Several termination mechanisms, including political influence, reform, and commission were used against the RAC program (Jenkins, Mondelli, Wilson, 2007).
The letter is just one example of the political influence used to end the RAC program. Therefore, even the members of congress who call for the reform of the RAC program, call for its termination. Instead, the program's operating costs are covered by a percentage of the money it returns to the federal government.
While the commissioning mechanism cannot end the RAC program, it may provide ammunition for those seeking to complete the program through another program. Second, as a 'watchdog' the RAC program benefits the nation as a whole, but its benefits are not tangible to a particular subset of the American people. The RAC program's initiative is to protect Medicare and Medicaid trust funds by identifying fraud, waste and abuse – making it the epitome of an oversight organization.
This fact may help explain the deviation of the RAC program from Kaufman's lifespan projection. Therefore, members of Congress are unlikely to be actively involved in the welfare of the program.
Conclusion
The single most influential factor in the termination of the RAC program was the lack of support from outside entities. When hospitals faced the administrative burden of claims audits and were forced to return government surplus funds they received, the AHA poured millions of dollars into lobbying efforts to stop the program. Despite the positive impact of the RAC on the life expectancy of Medicare and Medicaid, the private sector was able to effectively terminate the program.
Retrieved January 2015 from https://www.cms.gov/About-CMS/Agency-Information/History/downloads/BushSignMMA2003.pdf. Retrieved March 1, 2015, from http://www.publicintegrity.org grassley-says-providers-who-overbill-medicare-are-draining-its-finances.
