Wiki RAC audit

[janetrose]

Our office received a RAC audit determination of several claims which the (commercial) carrier states did not meet the level of care which was billed. I requested that the carrier provide me with the audit worksheets so that we can review and respond and they have refused to provide either the worksheets or tell us the specific element that they feel is insufficient. Are we not entitled to this information in order to respond? They claim we are not.

 

[thomas7331]

I would start by reviewing your provider's contract with this particular commercial carrier. Whenever you are dealing with a commercial payer, then your rights with regard to appeals and audits are going to be determined by the terms of your contract with that payer. In some cases, if the patient is covered by a fully insured plan within your state, then your state's insurance regulations may also apply, in which case you may wish to contact your state insurance commissioner's office to see if they can offer any remedies as well.