RAC Audit Process Attorneys

Medicare audits can be a very complicated and confusing process. That doesn’t mean that they have to be. If you face a RAC audit, you want to know that the professionals on your side can help. The lawyers at the Norman Spencer Law Group are your best choice! We have years of experience practicing in the legal healthcare field. Our lawyers successfully handle Medicare Recovery Audit Contractor (RAC) audits, as well as Safeguard and ZPIC Medicare audits. We’ve helped many licensed healthcare professionals and practices respond to audits and defend their claims.

What’s the Role of RAC?

The goal of Recovery Audit Contractors is to identify any potential underpayments and overpayments. They do this by reviewing past Medicare claims. The auditors focus on areas that have a high susceptibility to errors. Those areas are typically identified by Comprehensive Error Rate Testing (CERT). CERT is a method that involves collecting documentation and conducting reviews of random samples of fee-for-service claims.

RAC uses proprietary software in order to pinpoint claims that are likely to be associated with improper payments. Then they investigate those claims in order to determine if the claim payment requires any kind of adjustment. These contractors generally don’t review claims that other Medicare contractors have handled. They also don’t create a payment policy. Payment policies in use by RAC follow the particular Medicare billing instructions, Medicare regulations, national coverage determinations (NCD), and the local coverage determinations (LCD).

How Does a RAC Audit Work?

The first step in the process is for RAC to identify a risk pool among all of the claims. The contractors will then request medical records from the healthcare professional in question. Once RAC receives the requested documents, contractors can review the medical records against the claim itself.

RAC then makes a determination based on its review. There are three potential options here: underpayment, overpayment, or correct payment. If RAC determines that an overpayment exists, it sends the case to the Medicare Administrative Contractor (MAC). The job of the MAC is to adjust the claim and recoup whatever the payment might be.

The MAC will send an overpayment notification letter to the healthcare professional. They can either pay back the money owed or appeal that determination using the normal appeal process. If providers decide to pay back the money to the Medicare program, they have several ways that they can repay it. They can pay by check, request an extended payment plan, or otherwise recoup from any future payments.

RAC Audit Notice of Determination

Healthcare professionals who receive a notice of determination by RAC have three options that they can choose from. These are discussion, rebuttal, and redetermination. These aren’t mutually exclusive, either.

The discussion option involves opening a dialogue with RAC about their specific determination in the case. The healthcare professional can submit any additional information to RAC. RAC can further explain how it came to the determination of whatever the recoupment amount comes out to be. If you choose this option, you would need to contact RAC with additional information within 40 days of receiving the original demand letter. Providers need to contact RAC directly in cases like these.

The rebuttal option allows healthcare professionals to provide a statement as well as evidence to show that an overpayment or recoupment action would result in some type of severe financial hardship for the professional in question. This option requires you to file that rebuttal within 15 days of receiving the initial demand letter. Providers need to contact MAC directly in any and all rebuttal cases.

The redetermination option is the first level of the appeals process. Redetermination requests need to be filed within 30 days of receiving that initial demand letter. While providers have up to 120 days to file for their final redetermination, filing within 30 days is going to avoid any offset. Providers will then file their redetermination requests directly to the MAC.

Timely RAC Responses

It is absolutely vital that healthcare professionals respond to demand letters in a timely and orderly fashion. Missing any of the filing deadlines can limit your available options. If providers don’t file within the 15 days that have been allotted for rebuttal, for instance, the rebuttal option might no longer be an option at all.

If you receive any type of demand letter indicating that the RAC has determined an overpayment exists, carefully review the claims in question. This is the most important thing that you can do at this point. You want to determine why and how the overpayment occurred. This can be a painstaking process, but it’s also one that the skilled attorneys at the Norman Spencer Law Group handle. We have helped so many clients analyze their claims and find the issue that resulted in a RAC audit or Medicare overpayment in the first place.

Healthcare professionals who try to defend themselves or their practices without an experienced healthcare law defense attorney have a high potential for a negative outcome in their situation. The case might not go as expected, and they’ll have no other recourse but to accept the outcome as final.

Being represented by a qualified healthcare law defense attorney is the best option by far. With an experienced defense lawyer by your side, your case has a much higher chance of favorable results. The lawyers at the Norman Spencer Law Group have been effective in many Medicare fraud cases, helping clients avoid criminal charges, severe monetary penalties, or placement on the Medicare fraud integrity watch list.

The moment that you receive that first demand letter based on a RAC audit determination of overpayment is the moment that you need to contact an experienced defense attorney for help. Call our office to schedule a consultation today.