Providers: High Rate of RAC, CERT Denials Overturned

Close to 50 percent of appealed recovery audit contractor (RAC) payment denials and Comprehensive Error Rate Testing (CERT) claim denials were overturned on appeal, according to the Centers for Medicare & Medicaid Services (CMS). The American Hospital Association (AHA) puts the number closer to 75 percent. Hospital officials say this is proof there are major problems in the CMS audit process, according to

Congressional staff has taken notice. The health website quotes a congressional aide as saying the number of successful appeals occurring for multiple years illustrates the need for a feedback loop incorporating auditors to let them know what kinds of payments or claims are frequently found during the appeals process to be improperly denied. The un-named aide said Congress is discussing potential policy options for creating such feedback.

A recent Office of Inspector General (OIG) report reviewing CERT errors overturned through the appeals process found that 53 percent of appealed denied claims were overturned in 2009. Providers appealed about 10 percent of denied claims in 2009, 16 percent in 2010, and 48 percent of those appealed were overturned. OIG says the overturned appeals were worth $6.1 million.


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3 Responses to “Providers: High Rate of RAC, CERT Denials Overturned”

  1. John Harrison says:

    It seems to me that 85% of the RAC audits I fielded were from incorrectly filed claims that were paid anyway, but over turned with a simple redetermination sheet. Or just auditors getting paid by volume, not quality. Most were because the auditors did not look into the case hard enough and just flagged them all and let the provider figure it out. Which causes undo hardship on an already taxed billing department. Like we don’t have enough senseless denials to deal with.

  2. Kristi May says:

    Maybe because there is a huge lack of communication amongst the government and the NUMEROUS agencys created to audit healthcare. Who governs these companies and advises them what to look for? Are they CPC’s or even trained auditors? All I see are articles throwing out the insane dollar amounts that are recouped without supporting facts/documentation. Therefore sounds to me like they are auditing for quanity and dollar signs. Scary thing for us practices who are caught up in the middle of this.

  3. Belinda says:

    First, I was under the impression that all RAC companies had to have A certified coder. There’s no way a RAC could effectively handle everything with one certified coder. Second, I think the government thinks there’s this huge problem with doctors intentionally committing fraud so they have items to look for. Since 95% of the doctors in America are honest, hard working people, they problem isn’t as bad as it seems. A few bad doctors who have taken a lot of money make the other doctors look bad. Not saying it doesn’t need to be reviewed, but it would seem to be wiser to put the money they’re paying RACs and put it to healthcare for the seniors

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