Updated: Jun 10
RAC Audit Process
Boost Advisory Group works with providers nationwide during Medicare RAC audits by providing the following services:
Education and training services; and/or,
Internal file review including medical records and billing requirement; and/or,
Documentation outreach services; and/or,
Appeal submission services.
Our team of DME Business Owners, Licensed Clinicians, and seasoned Product Experts have extensive experience in Medicare audits, including MAC, CERT, TPE, RAC, and ZPIC audits. Our team has over 50 years of combined experience and has an historical win rate that exceeds 90% of all claims submitted.
Recovery Audit Contractors (RAC) review previously paid Medicare claims for potential overpayments or underpayments. There are a few characteristics about RAC Contractors that business owners must know:
Recovery Audit Contractors (RAC) only get on improper payments that they discover. This fee ranges from 9% to 12% depending on the contractor.
The RAC focuses their review on areas identified by the CERT’s as having a high propensity for error.
The RAC uses proprietary software to identify claims that are likely to contain improper payments. The RAC typically does not review claims that have already been reviewed by another Medicare contractor.
The RAC does not create the payment policy. The payment policy used by the RAC is determined by Medicare regulations, Medicare billing instructions, NCD’s and LCD’s.
The RAC Process
Risk pool of claims is identified
RAC requests medical records from the provider
RAC will review the files and determine if an improper payment was made
If an overpayment is found, the RAC sends the file to the MAC to adjust the claim and recoup the payment(s).
The RAC will send an overpayment letter to the provider
The provider has three options at this point in time (these are not mutually exclusive of each other)
1. Here the provider can discuss the determination with the RAC
2. The provider can submit additional information to the RAC
3. The RAC can provide additional clarity regarding the decision
4. Provider must contact the RAC and submit additional information to the RAC within 40 days of the Demand Letter.
1. The provider can submit a statement and evidence showing that a recoupment would cause significant hardship for the provider.
2. This process is not used to fight the recoupment decision or to submit additional medical records
3. Rebuttal letters must be filed within 15 days of the date of the Demand Letter.
4. You must contract the MAC directly to exercise the rebuttal option
1. This is the first level of this appeals process
a. You have 120 days to file a redetermination but you should file within 30 days to stop the recoupment process
b. Redeterminations in this process are sent to the MAC just like the typical appeals process.
7. What happens if we lose?
a. If an overpayment is ultimately decided, you have a few options
1. Pay the balance by check
2. Request an extended payment plan
3. Allow recoupment from future payments
The odds in a RAC audit are stacked against you. Don’t try and defend a Medicare Audit by yourself. Remember, the RAC only gets paid if they find improper payments so it is imperative to your success that you work with someone who can successfully navigate you through the process.
Boost Advisory Group was established to provide expert guidance and world-class support in the areas of payor audits, healthcare consulting, education, and medical records compliance. Our dedicated and perfectly balanced team of clinicians, executive leaders, and product specialists deliver effective, accurate and precise solutions to help companies navigate through the regulatory hurdles. All while helping our partners achieve operational and financial excellence through improved knowledge, quality and compliance.