RAC Audits and Overpayment Appeals

Recovery Audit Contractors (RACs) are single-function contractors primarily charged with auditing Medicare claims for overpayments or underpayments.  Accordingly, the RACs can institute recovery actions to recuperate incorrect payments, i.e. overpayments.  A RAC claim review can include Medicare claims paid as far back as 2007, resulting in an overpayment determination for millions of dollars.  It is critical for a Medicare provider or supplier to be represented by health care attorneys that truly understand governmental audit standards, have experience challenging Medicare overpayment determinations, and possess a sophisticated understanding of the Medicare statute and regulations.

The attorneys at Gaitan Law Group have the requisite industry, government and legal experience necessary to counsel clients who receive a Medicare RAC audit letter, as well as those seeking to appeal an overpayment determination.  From an automated desk review to a complex audit, we represent Medicare providers and suppliers who need to protect their hard earned reimbursement monies from recoupment.

Medicare providers and suppliers facing a RAC audit will find that our attorneys truly understand the many rules and restrictions of the RAC program.  We make sure that the scope of a RAC review is limited only to those issues approved by CMS and posted approved on the RAC’s Web site; and we verify that record requests are properly made and response times correctly calculated. in order to protect Medicare providers and suppliers from improper recoupment and business interruptions.

Unlike the ZPICs, RAC audits are not focused on identifying fraud and abuse.  Although they lack jurisdiction to investigate and prosecute fraud, the RACs can report any suspicion of fraud or abuse to the ZPICs, such that a successful RAC overpayment recoupment may be followed by a fraud investigation by a ZPIC.  Thus, Medicare providers and suppliers should take affirmative steps to prepare and/or respond to a Medicare audit.

At Gaitan Law Group, our attorneys work with Medicare providers and suppliers to prepare and respond to RAC audits.  Our clients benefit from our lawyers’ proven ability to aggressively confront reimbursement and compliance issues throughout administrative processes and judicial proceedings.  Our attorneys have developed unique strategies to train clients on RAC preparedness and responsiveness including developing an internal RAC response team; managing medical record requests; collaborating and negotiation with RAC contractors; and appealing RAC overpayment determinations before the Fiscal Intermediary, Qualified Independent Contractor (QIC), Administrative Law Judge (OMHA-ALJ), Departmental Appeals Board (DAB), and appealing cases to the US Federal District Court whenever necessary.  Most importantly, our health care attorneys understand first-hand that responses to a RAC audit must be timely, compliant and legally sufficient in oder to preserve aMedicare provider or supplier’s interests. 

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