Medicare's Recovery Audit Contractor Program: RAC Reviews and Appeals


In order to ensure accurate payments under the Medicare fee-for-service program, the Centers for Medicare & Medicaid Services (“CMS”) has implemented the Recovery Audit Contractor (RAC) program. RACs utilize a post-payment targeted review process employing data analysis techniques in order to identify those Medicare claims most likely to contain overpayments. The RAC review is either automated, for which a decision can be made without requesting a medical record, or complex, for which the RAC will contact the provider in order to review the medical records to make a decision about the payment. A RAC may review initial determinations within three years from the date of notice of the initial determination or redetermination if there is good cause. However, RACs will not be able to review any claims paid prior to October 1, 2007. This Health Care Alert provides the most recent information from CMS regarding the start dates for automated and complex reviews, “good cause” claim reopenings, the five-level Medicare appeals process, limitations on recoupment of alleged overpayments, and charts on the RAC process and Medicare appeals process.

To view the full alert and charts outlining the RAC Process and RAC Review Appeals Process, click on the PDF below.

If you need advice or assistance with Medicare’s Recovery Audit Contractor Program, please contact one of the attorneys below.

Stacy L. Brainin

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