Recovery Audit Contractor Information (RAC)

The following information is mostly from the CMS/HHS.gov website(. This means that sadly, the URLs for these may change at some point. In fact, they probably will.

If the links do not work, would you please send an email to Leslie about it so this page can be updated? Appreciate your help.

Contents on these pages can be viewed by hovering over the icon to the left of the links with your mouse. They can also be printed.

They can also be downloaded directly, by right-clicking on the link with your mouse and opening to a new window.

Appeals Process Diagram - From CMS

Appeals Process Directions - From CMS MedLearn Matters (MLM) - Sept. 12, 2008

Appeal Update Report from CMS showing that only less than 25% of the providers audited appealed; 34% of those WON. This very interesting study was published in January, 2009.

Automated Review - FAQs from HHS.gov:

RACs may use automated review (where NO medical record is involved in the review) ONLY in situations where there is certainty that the claim contains an overpayment.

Automated review must: a) have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment); b) be based on a medically unbelievable service; or c)occur when no timely response is received in response to a medical record request letter.

FAQs from AAFP

Limitations on Recovery - (935) for Provider, Physicians and Suppliers Overpayments - Information you need from CMS Internet Only Manual 100-06, Sept. 2008. Even Medicare has Recoupment limits!

Limitations on Recovery (935) for Provider, Physicians and Suppliers Overpayments - Information from CMS MedLearn Matters (MLM), Sept. 12, 2008

Reimbursement for Records - HHS FAQs

"RACs are required to reimburse PPS providers and Long Term Care providers.

The reimbursement rate is 12 cents per page for reproduction of medical records. Facilities are not required to submit vouchers to the RAC requesting payment. Rather, the RACs will automatically issue payments to the hospitals for photocopying charges. RACs are required to pay for copying on a monthly basis. All checks should be issued within 45 days of receiving the medical record."

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