Recovery Auditor Appeals

The Recovery Audit Contractor program has provided CMS with a new mechanism for detecting improper payments made in the past and has given CMS a valuable new tool for preventing future overpayments.

The RAC scope of work includes identification of improper payments that are a result of:

  • Incorrect payment amounts
  • Non-covered services (including services that are not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act)
  • Incorrectly coded services (including DRG miscoding)
  • Duplicate services

ACS consultation to assess the hospital's risk for improper Medicare payments (both underpayments and overpayments) for inpatient and outpatient services includes:

  • Extensive data analysis for development of a customized chart review plan;
  • Medical record review with an evaluation of coding accuracy, documentation adequacy and a review of level of care determinations (Inpatient / Outpatient / Observation Services);
  • Review of policies, procedures and processes for coding, physician query, utilization review, CDI and RAC coordinator;
  • Interviews with key hospital staff to allow for better understanding of the internal processes related to coding and billing accuracy;
  • Customized educational sessions for coding, billing, clinical staff, UR / case management, medical staff and hospital leadership.

ACS is also available to assist hospitals in preparing appeal letters to challenge incorrect RAC decisions.  See Appeals Process / Expert Witness.