Prompt Action On Medicare Appeals Avoids Recoupment

Providers should know that if they plan to appeal a Recovery Audit Contractor’s (RAC) determination of overpayment they can avoid recoupment at the first and second levels of appeal if they act super timely.

The regular time-frame for appealing a RAC overpayment determination is as follows. Providers have 120 days from receipt of a notice of the initial overpayment determination to initiate the first level of appeal known as the redetermination. For the second level of appeal, reconsideration, providers must file their appeal request within 180 days from receipt of a redetermination decision. For the third level of a RAC appeal, the Administrative Law Judge hearing, a request must be made within 60 days following the reconsideration decision.

The next level of review is the Medicare Appeals Council, and the request to be heard there must be made within 60 days following a decision at the ALJ hearing.  The final level of appeal for providers is judicial review in a federal court which must be taken within 60 days of the decision of the Medicare Appeals Council.

If providers adhere to these time-frames, they would have filed a timely appeal but that alone would not prevent Medicare from initiating a collection of the overpayment amount. If providers act super timely, however, they can stop an offset at the first two levels while the appeal is proceeding.  That means that after receiving a determination of an overpayment amount provider must not wait the allotted 120 days to appeal but must appeal within 30 days. Similarly, to prevent recoupment at the second level of appeal, providers must appeal within 60 days and not wait to file within 180 days, if they want to avoid recoupment.

Even when recoupment is stopped for the first two levels of appeal, however, interest continues to accrue, and a provider would eventually have to repay the overpayment determination plus interest if unsuccessful on appeal.

If you have questions about the RAC appeals process or need other legal assistance, please contact us.