Consider Medicare Audit Appeal

There is an important reason for doctors to consider appealing the Recovery Audit Contractor (RAC) overpayment determination.

Similar to the original Medicare Part A & B fee-for-service appeals process, the appeals process for overpayment determinations made pursuant to the RAC program has 5 levels following the initial determination of overpayment :

  1. Redetermination by the fiscal intermediary
  2. Reconsideration by a Qualified Independent Contractor
  3. Administrative Law Judge Hearing
  4. Medicare Appeals Council Review
  5. Judicial Review in U.S. District Court

While providers may be hesitant to appeal RAC audit determinations, there is good reason to consider otherwise. The Centers for Medicare & Medicaid Services analyzed the data collected from the RACs demonstration projects and the numbers tell an interesting story. While providers appealed RAC determinations only at the rate of 12.7% (76,073 out of 598,238 overpayment determinations), 64.4% of appealed claims were decided fully or partially in provider’s favor.

If providers decide to appeal, they should not delay the process as timing is critical to secure the appeal rights.

Our office represents providers during Medicare and Medicaid audits. For more information, please contact us here.