Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 02, 2010 PDF

If you aren't used to dealing with recovery audit contractor (RAC) requests, you're not alone -- but a new CMS Q&A could help you clarify what to do when you receive one.

On July 16, CMS updated a RAC Q&A on its Web site, shedding light on the differences between the RAC discussion period and the rebuttal and redetermination processes.

Discussion period: Once you receive a demand letter for automated review, you have between one and 40 days when you can contact the RAC and enter into a "discussion period." This period "offers the opportunity for the provider to provide additional information to the RAC to indicate why recoupment should not be initiated," and also allows the RAC a chance to explain the reasons for the overpayment decision, CMS notes on its Web site.

After the RAC reviews any additional documentation that you've submitted, it could reverse its decision, and will send you a letter "detailing the outcome of the discussion period." 

Rebuttal process: Once you receive a demand letter from a RAC, you have from one to 15 days to contact the MAC and open a rebuttal process, during which time you can submit evidence indicating why an overpayment action would cause a financial hardship and should not take place. "A rebuttal is not intended to review supporting medical documentation nor disagreement with the overpayment decision," the CMS site indicates.

Redetermination: This denotes the first level of appeal, and you should contact your MAC for a redetermination. "The timeframe is between day one and 120 upon receipt of the demand letter," the Q&A states. "It must be submitted within 120 days of receipt of demand letter. To prevent offset on day 41 the Redetermination must be filed within 30 days."

To read the Q&A and find a link to a RAC chart, visit http://questions.cms.hhs.gov/app/answers/detail/a_id/9994/kw/rac.