Medicare Audits and Appeals and RAC Audits
WACHLER & ASSOCIATES, P.C. has defended over 2000 Medicare, Medicaid, and third party payor audits. The attorneys have unparalleled experience successfully defending Medicare, Medicaid, and other third party payor audits on behalf of healthcare entities, providers and suppliers nationwide. Please visit our website dedicated to RAC and Medicare Audits!
Medicare providers and suppliers can expect increased Medicare audit activity as the Recovery Audit Contractor (“RAC”) program expands nationwide, beginning this year. To view CMS’s most recent “Expansion Schedule,” please click here.
The RAC demonstration program was mandated by Section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which directed the Department of Health and Human Services (“HHS”) to conduct a three-year demonstration program using RACs. The RAC demonstration program began in 2005 in California, Florida and New York, the three states with the highest Medicare expenditures. In 2007, the program expanded to include Massachusetts, South Carolina and Arizona. The purpose of the RAC demonstration program was to determine whether the use of RACs would be a cost-effective way to identify and correct improper Medicare payments.
The RAC demonstration program proved highly “cost effective” from the point of view of CMS. Over the course of the three-year demonstration, the RACs identified and collected more than $1.03 billion in improper payments. According to CMS, factoring in the underpayments returned to providers and suppliers, the claims overturned on appeal, and the operating costs of the demonstration program, the RAC program was successful in returning $693.6 million to the Medicare Trust Funds. CMS estimates that the RAC demonstration program cost approximately 20 cents for each dollar returned to the Medicare Trust Funds. To view the RAC Demonstration Evaluation Report, please click here. To view the most recently updated report (which accounts for additional appeals data), please click here.
Section 302 of the Tax Relief and Health Care Act of 2006 made the RAC program permanent and required its expansion nationwide by no later than 2010. CMS has already begun to move forward with this expansion. According to its most-recently published “Expansion Schedule,” CMS planned to expand to 19 states by October 1, 2008 (including Michigan), four more states by March 1, 2009, and the remaining states by August 1, 2009 or later. Therefore, Medicare providers and suppliers nationwide can expect RAC auditing in the very near future.
When providers are notified of a RAC audit, they must endure an often-burdensome process involving dedicating resources to timely submitting records and defending claims denials. CMS has provided the RACs with a significant financial incentive to aggressively review and deny claims, meaning that Medicare providers and suppliers should begin preparation to make this process easier to undergo. Additionally, providers and suppliers should be aware that if they are dissatisfied with a RAC review determination, they have a right to appeal through the Medicare appeals process. This process includes five potential stages: (1) a redetermination to the Carrier or Fiscal Intermediary; (2) a reconsideration submitted to a Qualified Independent Contractor; (3) an appeal to an Administrative Law Judge; (4) an appeal to the Medicare Appeals Council; and finally, (5) an appeal to Federal district court. Each level of appeal carries with it certain requirements with which appealing providers much comply, as failure to follow these requirements could result in the inability to continue the appeals process.
Having worked on thousands 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 CMS’s web page regarding the RACs, please click here.
PUBLICATIONS
"Get Ready -- Recovery Audit Contractors Are Coming to Michigan", by Andrew B. Wachler, Esq., Michigan Medical Law Report, Vol. 4, No. 4, Winter, 2009
"Recovery Audit Contractors and Medicare Audits: Successful Strategies for Defending Audits", by Andrew B. Wachler, Esq., Radiology Business Journal, Vol. 3, No. 8, August 13, 2008
“RAC to the Future: What Can Medicare Providers and Suppliers Expect from the Recovery Audit Contractor Program?", by Andrew B. Wachler, Esq. , The Health Lawyer, The ABA Health Law Section, Vol. 21, No. 2, December, 2008
“The RACs Are Coming – Are You Ready?” by Andrew B. Wachler, Esq., The RAP Sheet, American Health Lawyers Association, Regulation, Accreditation and Payment Practice Group, December 2008.
"Recovery Audit Contractors and Medicare Audits: Successful Strategies for Defending Audits", by Andrew B. Wachler, Esq., Caring, National Association of Home Care and Hospice, November, 2008
“Recovery Audit Contractors and Medicare Audits: Successful Strategies for Preparing for and Defending Audits,” by Jennifer M. O’Brien, Esq. and Andrew B. Wachler, Esq., Journal of Health Care Compliance, September-October, 2008
“The Medicare Appeals Process and Strategies for Successful Appeals,” by Andrew B. Wachler, Esq. American Health Lawyers Association, Physician Organizations, Vol. 10, Issue 1, Winter, 2007
“Get Ready: The RACs May Be Nationwide Sooner Than Expected!” by Andrew B. Wachler, Esq., HCCA Compliance Today, 2007.
“The New Medicare Part A and Part B Appeals Process,” by Andrew B. Wachler, Esq., Esq., Health Law Handbook 2006, Part I, Chapter I, 2006.
“The New Medicare Appeals Process,” by Andrew B. Wachler, Esq., The Health Lawyer, The ABA Health Law Section, June 2005.
SPEAKING ENGAGEMENTS
"RAC and Medicare Audits" Ambulatory Surgery Center Association (ASCA), November 17, 2009.
"Current Legal Issues of Hospices," National Hospice Work Group, October 23, 2009.
"RACs and Medicare Audits: Compliance Tips and Successful Appeal Strategies," National Association of Homecare & Hospice (NAHC), October 13, 2009.
"Latest Developments Related to the Nationwide Expansion of the Recovery Audit Contractors," Michigan Bar Association Health Law Section, September 24, 2009.
"Building a RAC Shield: Best Practices in Preparedness & Case Studies of Success," The 4th Annual Hospital and Health System Financial Management Congress, Co-Presented with Susan Bihler, Director of Utilization Management at Florida Hospital, September 22, 2009
"Recovery Audit Contractors: An Overview of Current Legal and Appeal Strategies," American Society of Medical Association Counsel (ASMAC), September 18, 2009
"Recovery Audit Contractors," 2nd National RAC Summit, September 14, 2009 - September 15, 2009
"RAC to the Future: New Developments, Current Legal Issues, and Appeals Strategies," American Bar Association Audio Conference, Co-Presented with Connie Leonard, Director, Division of Recovery Operations for CMS, August 13, 2009.
"RACs & Medicare Audits: Compliance Tips and Successful Appeals Strategy," Indiana Association for Home & Hospice Care, May 19, 2009 - May 21, 2009.
"Recovery Audit Contractors & Medicare Audits: Compliance Tips & Successful Appeals Strategies," Healthcare Billing and Management Association, May 7, 2009
“Recovery Audit Contractors and Medicare Audits,” 2009 Spring Educational Conference of the Healthcare Billing and Management Association, May 6-8, 2009
"RAC Audit Appeals- Strategies and Defenses for Overturning Hospital RAC Denials," National Healthcare Compliance Audioconference, May 5, 2009
“Ready or Not, Here They Come! Preparing for and Defending RAC Audits,” 2009 Annual Meeting of the Health Care Compliance Association (HCCA), April 27, 2009
“The Basics: How the RAC Appeals Process Works,” National Medicare RAC Summit, March 5, 2009 – March 6, 2009
“Recovery Audit Contractors and Medicare Audits,” 2009 American Bar Association (ABA) Emerging Issues Conference, February 18, 2009 – February 20, 2009
“Managing the Recovery Audit Contractor Review Process,” World Research Group, December 8, 2008 – December 9, 2008
“Recovery Audit Contractors: Past, Present and the Future,” 2008 American Bar Association (ABA) Health Care Law Section Washington Summit, November 17, 2008 – November 18, 2008 (with Melanie Combs-Dyer, senior technical adviser for CMS’ division of recovery audit operations)
“Recovery Audit Contractors & Medicare Audits,” National Hospice & Palliative Care Organization (NHPCO), October 24, 2008
“Recovery Audit Contractors & Medicare Audits: Successful Appeals Strategies and Compliance Tips,” 2008 Annual Meeting of the National Association of Home Care & Hospice (NAHC), October 11, 2008 – October 15, 2008
“New Developments in Medicare Audits: Recovery Audit Contractors – Defense and Compliance Strategies,” 2008 Radiology Business Management Association (RBMA) Annual Meeting, September 4, 2008 – September 6, 2008
“Recovery Audit Contractors: Everything You Wanted to Know About RACs… But Were Afraid to Ask,” American Bar Association (ABA) Health Law Section Webcast, August 13, 2008 (with Melanie Combs-Dyer, senior technical adviser for CMS’ division of recovery audit operations)
“The Medicare Appeals Process and Strategies for Successful Appeals,” Michigan Home Health Association (MHHA), May 14, 2008
“Recovery Audit Contractors and Medicare Audits,” 2008 Radiology Summit of Radiology Business Management Association (RBMA), May 4, 2008 - May 7, 2008
Advanced Appeals Workshop, 2008 American Health Lawyers Association (AHLA) Institute on Medicare and Medicaid Payment Issues, April 9, 2008 – April 11, 2008
“RAC Audits and Medicare Appeals,” 2007 American Bar Association (ABA) Washington Healthcare Summit, December 3, 2007 - December 4, 2007
“Third Party Payor Audits,” American Society of Addiction Medicine, April 26, 2007 – April 29, 2007
“The Medicare Appeals Process,” 2007 American Health Lawyers Association (AHLA) Annual Physicians and Physicians Organizations Law Institute, 2007
“New Developments in Third Party Payor Audits,” 2007 Radiology Summit of Radiology Business Management Association (RBMA), 2007
“The Medicare Appeals Process,” 2007 Annual Meeting of the Michigan Hospice and Palliative Care Organization (MHPCO), 2007
“The New Medicare Appeals Process,” Annual Meeting of the American Academy of Ophthalmology, November 11, 2006 - November 24, 2006
“The New Medicare Appeals Process,” Annual Meeting of the Medical Group Management Association (MGMA), October 25, 2006
“The New Medicare Appeals Process,” 2006 Annual Meeting of the Health Care Compliance Association (HCCA), October 1, 2006 - October 3, 2006
“The New Medicare Appeals Process and Strategic Approaches to Medicare Audits,” 2006 Annual American Health Lawyers Association (AHLA) Annual Physicians and Physicians Organizations Law Institute, August 2, 2006 - September 2, 2006
“The New Medicare Appeals Process and Strategies for Successful Appeals,” American Bar Association (ABA) Health Law Section Teleconference, 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 (MHPCO), 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 (AHLA) 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
