RAC Audit Process
How the RAC audit appeals process works
In our last E-Zine we discussed some basic information about RAC audits and the process in which RACs will be implemented. We also discussed some of the focused areas of review. In this E-Zine we are going to discuss the RAC appeals process and briefly touch on what you as an agency should be aware of if you plan on appealing.
The first question an organization must ask itself is whether you want to appeal any findings that may have been discovered during the RAC audit. The reason this is an important question is because the cost benefit in appealing the RAC audit findings may not be justified.
The amount of resources you will need to focus on going forward with the appeal must be taken into consideration. You have to keep in mind it is not always about who is right and who is wrong, but what is the net cost to your organization. Unfortunately, there is no end date to the RAC audit program and the process can be repeated every 45 days. This makes it prudent to address audit issues in addition to appealing the overpayment. Even if you choose to appeal, you will most likely have the same findings come up again in the next 45 day cycle if you do not address the underlining audit issues.
There are many other factors your organization may want to consider and those are completely subjective. In the next section we will discuss the 5 major levels of appeals including the Discussion Period which you may want to consider.
Before we discuss the different levels of appeal it is important to understand what will make your agency successful in proceeding in this direction. As we mentioned earlier, it may become very costly to move up the appeals process ladder. Many of these costs will include expert advice, including lawyers, which also help your chances of overturning an overpayment. In addition, to have the proper resources within your agency, please familiarize yourself with all documents required for each level. It is important to understand what is required in order to allow you to appeal an overpayment before spending the resources. Keep in mind that by appealing you are not delaying the repayment back to the RACs.
Let’s talk about the Levels of Appeal
Unlike many other recovery programs the RAC audits have something titled the Discussion Period . This is something many agencies can do before you begin the appeals process. Regardless of the type of review (complex or automatic), you must initiate the discussion within 15 days of an overpayment demand letter. After the discussion process begins the RACs may have the overpayment withdrawn or they may decide to continue with their original decision. Regardless of the outcome it is important to understand that the clock has not stopped in regards to your time frame for filing an appeal. The RAC has up to 60 days to respond, so make sure you plan your appeal at the same time.
Level One Appeal: Redetermination
This is your first level of appeal and you have a 120 day time frame to file for Redetermination . As with the Discussion Period , you will either have results that your appeal has been denied or overturned. Typically the RAC is required to respond within 60 days. This is where you may receive a partial payment amount or no payment at all.
Level Two Appeal: Reconsideration
If you were denied in your first appeal you have the right to request a second level of appeal, Reconsideration . You will be given a CMS form for Reconsideration with your letter of denial. Keep in mind that this is the time for all considered documentation. No additional documentation will be accepted beyond this appeal level (as in new introduced documentation). You have 180 days to file for Reconsideration following your letter of denial of Redetermination.
Level Three Appeal: Administrative Law Judge (ALJ)
If your appeal has been denied in the Reconsideration level you can then take it to the Administrative Law Judge , this must be done within 60 days after your letter on the reconsideration request. These Administrative Law Judges are attorneys who work for HHS.
Level Four Appeal: Medicare Appeals Council
If you feel that the ruling by the Administrative Law Judge is not just, you have the opportunity to bring it to the Medicare Appeals Council . Just like the other levels the Medicare Appeals Council can overturn or uphold a previous opinion, however, they can also send the appeal back down to the Administrative Law Judge for an additional hearing. Again, like other appeals you have a specific time in which you can appeal. This level requires 60 days in which you can apply.
Final Appeal Level: Judicial Review
This is the final level of appeal, you must have a very strong case and dedicated resources to proceed. Not many appeals make it to this level. At this point you are filing a suit in a federal district court. The costs must justify the overall outcome (you may want to just change your documentation or process for future consideration as to not allow for additional overpayments in the future.)
The process can be challenging. However, agencies should find themselves in a position that requires consideration of the first few levels of appeal. Familiarize yourself with the process and it may benefit your organization. There are many organizations that can help you with this process. Other suggestions include doing RAC preparedness audits within your agency. Select Data, in addition to providing such audits, has software tools like our SmartAuditâ„¢ tool that allow you to manage the appeals levels we just discussed.
Please feel free to contact one of our representatives on how we can assist your agency.