Medicare Audits and Appeals and RAC AuditsWACHLER & ASSOCIATES, P.C. has worked on over 2000 Medicare and other third party payor appeals. The attorneys have extensive experience in defending Medicare audits and successfully appealing overpayment demands and denied claims. Providers should expect to see an increase in Medicare audit activity as the Recovery Audit Contractor (RAC) demonstration project implemented in California, Florida and New York will be expanded nationwide as early as 2008. The Centers for Medicare and Medicaid Services (CMS) executed the RAC demonstration in 2005 under Section 306 of the Medicare Modernization Act in order to establish whether RACs are an efficient method of identifying and correcting improper payments to providers. The three states were chosen on the basis of their being the top states of Medicare consumption. Two types of RACs were hired in each state: Claim RACs, to identify overpayments and underpayments, and Medicare Secondary Payer (MSP) RACs, to distinguish situations in which another insurance company should have made the payment. Evaluations of the demonstration have determined that even considering the fees paid to the RACs for their services, the Medicare Trust Fund has gained a substantial amount of funds. Accordingly, CMS plans to extend the program throughout the entire country, possibly beginning as early as 2008. As of November 2006, a total of 303.5 million dollars of improper payments had been identified, and according to CMS, most of the overpayments actually collected fell between 10,000 and 19,999 dollars. CMS notes that the overwhelming majority of all overpayments discovered and remedied were those collected by the Claim RACs. In fiscal year 2006, Claim RACs collected 94% (64.6 million dollars) of the overpayments, leaving MSP RACs with only 4% (4 million dollars). These types of overpayments involve situations in which the Claim RACs assert that the health care providers incorrectly coded claims, performed services that were not medically necessary, or billed multiple times When providers are notified of a RAC audit, they must endure an often burdensome process that includes dedicating resources to locating and submitting records as well as defending claims denials. CMS has provided the RACs with a significant financial incentive to aggressively review and deny claims, meaning that health care providers should begin preparation to make this process easier to undergo. Furthermore, if providers are dissatisfied after the initial decision, they have a right to appeal according to the customary Medicare appeals process. This includes five potential stages: a redetermination to the Carrier or Fiscal Intermediary; a reconsideration submitted to a Qualified Independent Contractor; an appeal to an Administrative Law Judge; an appeal to the Medicare Appeals Council; and finally an appeal to Federal district court. Each level of appeal carries with it certain guidelines that must be adhered to, as failure to follow them could result in the inability to continue the appeals process. Having worked on 2000 Medicare appeals, the attorneys at WACHLER & ASSOCIATES, P.C. are highly qualified to assist providers and other third party payors in the Medicare appeals process. Please contact us at (248) 544-0888 if you have any questions or if you would like assistance in this area. To view the CMS RAC Status Document for the 2006 fiscal year, click here. To view frequently asked questions regarding RACs, click here. To find out more about the implementation of RACs throughout the United States, visit the Center for Medicare and Medicaid Services' RAC Expansion Strategy page. To view the map of proposed RAC jurisdictions, click here. PUBLICATIONS"Get Ready: The RACs May Be Nationwide Sooner Than Expected!" by Andrew B. Wachler, Esq., Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., HCCA Compliance Today, 2007. "The New Medicare Part A and Part B Appeals Process," by Andrew B. Wachler, Esq. and Abby Pendleton, Esq., Health Law Handbook 2006, Part I, Chapter I, 2006. SPEAKING ENGAGEMENTS"RAC Audits and Medicare Appeals," ABA's 5th Annual Washington Healthcare Summit, December 3, 2007 - December 4, 2007 "Third Party Payor Audits," American Society of Addiction Medicine (ASAM), April 26, 2007 - April 29, 2007 "The New Medicare Appeals Process and Strategies for Successful Appeals," American Bar Association Health Law Section, June 2006 "The New Medicare Appeals Process," Associated Professional Sleep Societies, June 2006 "The New Medicare Appeals Process and Strategies for Successful Appeals," Michigan Hospice and Palliative Care Organization, May 2006 "The New Medicare Appeals Process," Michigan Podiatric Association, March 2006 "The New Medicare Appeals Process and Strategic Approaches to Medicare Audits," American Health Lawyers Association Annual Physicians and Physicians Organizations Law Institute, February 8, 2006-February 9, 2006 "Medicare Appeals, Exclusive Contracts, Compliance, Legal Risks of Facility Ownership, Society for Pain Practice Management," September 2005 |
