What To Do When The RAC Attacks

What To Do When The RAC Attacks

By Paul W. Kim, JD, MPH and James B. Wieland, JD
The CMS bounty hunters are on the loose, and they could come knocking on the door. What can you do? Get ready for an audit by following the steps below, and educate yourself as to how the appeal process works.
In August 2010, the Centers for Medicare and Medicaid Services (CMS) kicked off it’s permanent, nationwide Medicare Recovery Audit Contractor (RAC) Program. Then, in April 2011, state Medicaid agencies initiated their statewide Medicaid RAC Programs. These bounty hunters are paid under contingency-fee arrangements to uncover overpayments and underpayments. This article will help you prepare for RAC audits.

Advance Preparation

Before the auditing begins, you should designate someone as the primary contact person. The contact person will play an important role throughout the audit process and should be responsible for receiving, conducting, documenting, and tracking all communication with a RAC.
It is best to establish policies and procedures. Health care providers should monitor CMS, state Medicaid agency, and any RAC websites to identify the particular issues that the RACs may audit.

Response and Appeal

When the audit actually begins, you should take a response and appeal approach. The response should always be timely and complete. The appeal process can require a series of steps.
When RAC requests medical records, you should document and track the requests until the medical records are submitted. You should confirm that the requests comply with any limits established by CMS or the state Medicaid agency. Always confirm that the RAC received the medical records and document the dates of submission and receipt.
If it has been determined that the Medicare program has overpaid you and you wish to appeal the findings, a Request for Redetermination may be filed with the local Medicare contractor within 120 days. If the decision is made that there will be an appeal made you should use the date of the demand letter, or the applicable appeal decision. Standard CMS appeal forms are available online for each level of appeal.
If the reconsideration decision is unfavorable, then a request may be filed with the Office of Medicare Hearings and Appeals (OMHA). A request for an in-person hearing requires a showing of good cause. If the issue is related to coding or a particular policy and its interpretation, either an on-the-record or a telephone hearing should suffice. Generally, a VTC hearing is better for appeals involving medical necessity.
If the decision is unfavorable, then you may file a request for review with the Medicare Appeals Council (MAC) within 60 days from the receipt of the ALJ decision.
If the MAC decision is unfavorable, then a complaint may be filed with the applicable U.S. district court within 60 days from the receipt of the decision. Of course, documentation is a key element to winning, and all filings and decisions should be documented and tracked.