IS YOUR ORGANIZATION READY FOR THE RAC ATTACK?

Get Ready for RACs, RACs, RACs and More RACs!

RAC EXPERIENCE

Attorneys with The Health Law Partners, P.C. gathered extensive experience with RAC audits and appeals, working directly with healthcare entities subject to RAC audits during the RAC demonstration program, which took place from 2005 to 2008.  Abby Pendleton, Esq. and Jessica Gustafson, Esq. lead the firm’s RAC and Medicare practice group. Ms. Pendleton and Ms. Gustafson have personally worked on numerous appeals of RAC claim denials made against hospitals, inpatient rehabilitation facilities (“IRF”) and physicians. They have prepared successful legal analyses and presented argument to Administrative Law Judges regarding RAC cases. They have achieved excellent results and recovered millions of dollars on behalf of providers.

Ms. Pendleton and Ms. Gustafson are contributing authors and speakers in numerous publications and speaking engagements on the topic of the RAC program and successfully appealing Medicare claim denials. A sampling of these publications and speeches includes:

"Recovery Audit Contractors and Medicare Audits: Strategies for Successful Appeals," 2010 Georgia Hospice and Palliative Care Organization Annual Leadership and Clinical Conference, February 25, 2010.

"Managing the RAC Appeals Process," A World Research Group Healthcare Management Conference: Reducing RAC and MIC Audit Exposure, December 7 through 8, 2009.

"Recovery Audit Contractors and Medicare Audits: Lessons Learned and the Road Ahead," 2009 American Health Lawyers Association Fraud and Compliance Forum, October 4 through 6, 2009 (with co-presenters Don Romano, attorney and Connie Leonard, Director, CMS Division of Recovery Audit Operations).

“Recovery Audit Contractors And Medicare Audits: What Can Hospitals and Health Systems Expect as the RAC Program Expands Nationwide?" co-authored: Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., American Health Lawyers Association, Hospitals and Health Systems Practice Group Member Briefing, January 2009.

"Get Ready -- Recovery Audit Contractors Are Coming to Michigan," co-authored: Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., Michigan Medical Law Report, Vol. 4, No. 4, Winter, 2009

"Recovery Audit Contractors and Medicare Audits: Successful Strategies for Defending Audits," co-authored: Jessica L. Gustafson, Esq., Radiology Business Journal, Vol. 3, No. 8, August 13, 2008

“RAC to the Future: What Can Medicare Providers and Suppliers Expect from the Recovery Audit Contractor Program?" co-authored: Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., The Health Lawyer, The ABA Health Law Section, Vol. 21, No. 2, December, 2008

“The RACs Are Coming – Are You Ready?" co-authored: Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., The RAP Sheet, American Health Lawyers Association, Regulation, Accreditation and Payment Practice Group, December 2008.

“Recovery Audit Contractors and Medicare Audits: Successful Strategies for Defending Audits,” co-authored: Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., Caring, National Association of Home Care and Hospice, November 2008.

“Recovery Audit Contractors and Medicare Audits: Successful Strategies for Preparing for and Defending Audits,” co-authored: Jessica L. Gustafson, Esq., Journal of Health Care Compliance, September-October, 2008

“The Medicare Appeals Process and Strategies for Successful Appeals,” co-authored: Jessica L. Gustafson, Esq., American Health Lawyers Association, Physician Organizations, Vol. 10, Issue 1, Winter, 2007

“Get ready for increased nationwide Medicare audit activity,” co-authored: Abby Pendleton, Esq., and Jessica L. Gustafson, Esq., Michigan Medical Law Report, Vol. 3, No. 3, Fall, 2007

“Get Ready: The RACs May Be Nationwide Sooner Than Expected!” co-authored: Abby Pendleton, Esq. and Jessica L. Gustafson, Esq., HCCA Compliance Today, 2007.

“The New Medicare Part A and Part B Appeals Process,” co-authored: Abby Pendleton, Esq., Health Law Handbook 2006, Part I, Chapter I, 2006.

“The New Medicare Appeals Process,” co-authored: Abby Pendleton, Esq., The Health Lawyer, The ABA Health Law Section, June 2005.

In addition to their RAC experience, the attorneys of The Health Law Partners, P.C. have worked on numerous other Medicare audits, including Program Safeguard Contractor, Intermediary and Carrier audits. Further, the attorneys of The Health Law Partners, P.C. also have experience representing healthcare entities subject to Medicaid and third party payor audits and claim denials.

RAC OVERVIEW

The Centers for Medicare and Medicaid Services (“CMS”) Recovery Audit Contractor (“RAC”) program began as a demonstration program mandated by Section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (“MMA”). The RAC demonstration program began in 2005 in California, Florida and New York, and later expanded to include Massachusetts, South Carolina and Arizona. RAC auditing activity under the RAC demonstration program concluded in 2008.

Section 302 of the Tax Relief and Health Care Act of 2006 made the RAC program permanent and required its expansion nationwide by no later than 2010. According to its most-recently published “Expansion Schedule,” CMS planned to expand to 23 states March 1, 2009, and the remaining states by August 1, 2009 or later. To view CMS’s most recent “Expansion Schedule,” please click here.

GET READY FOR RACs!

RACs are compensated on a contingency fee basis, based upon the principal amount of improper Medicare payments corrected. Thus, the RACs have a significant financial incentive to aggressively review and deny claims.

When providers are notified of a RAC audit, they must endure an often-burdensome process involving dedicating resources to timely submitting records and appealing claim denials. Accordingly, we recommend providers begin now to take steps to prepare for the RACs, including the following:

• Assemble appropriate personnel to monitor communications from the RACs and internally track appeal deadlines
• Carefully monitor areas that may be subject to RAC scrutiny and increase compliance efforts in those areas. Although areas of RAC scrutiny cannot be predicted with certainty, providers and suppliers can review the types of denials made during the RAC demonstration and other Medicare guidance, such as the Office of Inspector General’s (“OIG’s”) annual Work Plan document.
• Steps to improve compliance could include the following, for example:
• Improving documentation
• For hospitals, carefully reviewing admissions and Utilization Review procedures
• Reviewing coding practices
• Education, education, education

RAC APPEALS

Providers and suppliers dissatisfied with a RAC review determination may appeal through the Medicare appeals process. This process includes five potential stages: (1) a redetermination to the Carrier or Fiscal Intermediary; (2) a reconsideration submitted to a Qualified Independent Contractor; (3) an appeal to an Administrative Law Judge; (4) an appeal to the Medicare Appeals Council; and finally, (5) an appeal to Federal district court. It is imperative that providers and suppliers follow the regulatory appeals timeframes to preserve appeal rights associated with denied claims. Failure meet appeal deadlines could result in a devastating financial impact to the provider or supplier.

RAC UPDATES - The HLP RAC Sheet

Every month, The HLP releases its RAC Sheet giving news and updates on RAC.  You can see the most recent RAC Sheet, and older updates, at our RAC Sheet Archives.

QUESTIONS REGARDING RACs?

RAC inquiries can be directed to Abby Pendleton, Esq. or to  Jessica Gustafson, Esq. at (248) 996-8510.