RAC Audit Appeals

Because Recovery Audit Contractor (RAC) audits are increasing, it’s important to understand how to respond in the event that your practice is audited. If it is determined that overpayments were made, providers have several appeal options at their disposal. In considering these options, bear in mind that responding early and accurately in the early stages of the audit process will increase the chance of early resolution.

The first action to consider is simply to submit a request for redetermination of the audit results. If that fails, a request for reconsideration may be directed to a Qualified Independent Contractor (QIC). For this to be acceptable, the provider must justify the appeal with relevant evidence.
If the claim is still denied, a series of appeals may be made, first to an administrative law judge, then to the Medicare Appeals Council. Finally, you appeal to have your case reviewed in federal district court.
In defending claims, providers may find it useful to utilize an expert in the field in question, especially in cases involving medical necessity. There are also several rules that may be invoked to bring about favorable resolution of the situation, including the “treating physician rule” and “provider without fault.”
Providers should not simply give up when a Medicare claim is denied; a range of options is available to assist in the appeals process. Learning about and taking advantage of these resources will assist the practice in regaining revenue lost through mistakes in filing claims.
For additional details, see the full article.
For additional information on the RAC audit process, an audio interview is available with Connie Leonard, director of CMS Recovery Audit Operations.