Appeals

RAC Appeals - Recovery Audit Contractor Denials

Washington & West has actual RAC Appeal experience and we achieved exceptional results for our clients that were affected in the demonstration states. We are a vital resource for provider’s looking for RAC consulting, RAC education, or RAC Appeal Services.

Once audited by the RACs, the process of responding can be quite burdensome, and often overwhelms the resources of many providers even if providers have a denial management team in place. The sheer volume of denials from a RAC audit can significantly impact the success of a provider appeal.

The difference between success and failure in the Medicare appeal process often depends upon how well the case is presented to the CMS reviewers at each level. Denied claims require and deserve an analysis that includes the following elements:

• Understanding of Medicare’s regulations and criteria
• Thorough review of the entire medical record
• Clear method of presentation of all necessary documentation and supporting explanation of the reason why the RAC is incorrect in its determination.

Washington & West can assist your facility at any point during the RAC appeal process. The levels of appeal are;

• Request for Redetermination to the FI/Carrier/MAC
• Request for Reconsideration to the Qualified Independent Contractor
• Request for Hearing to the Administrative Law Judge
• Request for Medicare Appeals Council Review

In addition, our services include follow-up until any retracted payments are returned to the provider, a very resource consuming, yet vital step in the recovery process. We are experts at analyzing Medicare criteria, law, and contract language to get denials overturned.

For a detailed description of the services and support that W&W provides at each level of appeal, contact us and we will send you more information by your preferred contact method.

Medicare’s Recovery Audit Contractor (RAC) History

Section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 directed the US Department of Health and Human services to contract with private companies in a demonstration project for the purpose of identifying incorrect Medicare payments and recouping Medicare overpayments.

The 3-year Demonstration project began in March 2005 in California, New York and Florida, with South Carolina and Massachusetts being “included” in the project. Arizona was also selected as a demonstration state, but due to provider pushback in California, all recoupment efforts for Arizona were put on hold.

The RACs were paid on a contingency fee basis, the first time the Medicare program had ever contracted this way. CMS typically used tax dollars appropriated by Congress to pay Medicare claims processing contractors, QIO and PSC, a budgeted amount to ensure that payment for claims is accurate.

The preliminary results for the RAC demonstration program for the period of 10/1/05 – 9/30/06 showed that the recovery auditors were a viable tool for CMS and they identified $289.1 million in overpayments. This prompted Medicare to pass the Tax Relief and Health Care Act of 2006, which mandated a national roll-out of the RAC program by 2010.

In response, Washington & West began speaking nationwide on the RAC program to prepare providers for the audits ahead as well as to assist hospitals affected during the RAC demonstration project. To request a presentation synopsis, please contact us.

The four permanent RACs are:

• Region A - Diversified Collection Services, Inc.
• Region B - CGI Technologies and Solutions, Inc.
• Region C - Connolly Consulting Associates, Inc.
• Region D - HealthDataInsights, Inc.