RAC Audit Process

First, the RAC identifies a risk pool of claims.  Second, the RAC requests medical records from the provider. Once the records are received by the RAC, they will review the claim and medical records. Based on the review, the RAC will make a determination: overpayment, underpayment or correct payment.

If it is determined that an overpayment exists, the RAC sends the file to the MAC to adjust the claim and recoup the payment. The Medicare Administrative Contractor (MAC) will notify the provider with an overpayment notification letter.

At that time, the medical provider can appeal the determination to the MAC. The normal appeal process applies. If an overpayment is owed back to the Medicare program, the provider has several options. The medical provider can pay by a check, allow recoupment from future payments, request an extended payment plan or appeal the determination.

After a physician or medical provider receives notice of a determination by a RAC, the provider can exercise three options: discussion, rebuttal and redetermination. These options are not mutually exclusive. 

First, the provider has an opportunity to “discuss” the determination with the RAC. The provider can provide additional information to the RAC and the RAC can further explain the rationale for the recoupment. The provider should contact the RAC and supply additional information within 40 days of the receipt of the Demand Letter. The provider should contact the RAC directly. 

Another option the provider may utilize is rebuttal. The provider can give a statement and evidence indicating why overpayment or recoupment action would cause a significant financial hardship for the provider. The rebuttal process is not used to disagree with the overpayment decision or to submit supporting medical documentation. Providers that wish to exercise the rebuttal option must contact the MAC directly. The rebuttal must be filed within 15 days of the date of the Demand Letter.

Finally, the provider can request a redetermination.  A redetermination is the first level of appeals. The redetermination request should be filed within 30 days from receipt of the demand letter (can file up to 120, but to avoid an offset should be filed in 30 days). The redetermination is filed to the MAC.

It is important for physicians or medical providers to respond in a timely manner to a demand letter based on a RAC determination that a Medicare overpayment exists. It is possible for the provider to limit their options by exceeding the time filing requirements. 

It is important to carefully review the claims that have been determined to be overpaid.  If an actual overpayment exists, a medical provider should try to determine how and why the overpayment occurred.  Chapman Law Group can assist physicians and medical providers to analyze their claims and to determine the cause for the RAC audit or Medicare overpayment.

Do not attempt to defend yourself or your practice without an experienced Medicare fraud attorney.  The potential for a highly prejudicial outcome is very high.  With a competent attorney focusing their practice in health care law, you have a much better probability of guiding the outcome and avoiding criminal charges or more severe monetary penalties or being placed on the integrity watch list by OIG for Medicare fraud.