Recovery Audit Contractor (RAC)

Recovery Audit Contractor Changes will be Major in 2014

(May 7, 2013): The Recovery Audit Contractor (RAC) program is slated to undergo significant changes in 2014. As discussed below, non-hospital health care providers and suppliers are likely to find the Medicare appeals process more complex than ever as RACs enter into the process in an effort to defend their denial decisions. I. Background of […]

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The Recovery Audit Contractor Program Continues to Expand its Medicare Footprint

(November 26, 2012): The Medicare Fee-for-Service (FFS) program consists of numerous payment systems, with a complex network of contractors that process more than one billion claims submitted by more than one million healthcare providers each year.[1] Medicare providers include hospitals, physicians, skilled nursing facilities, labs, ambulance companies, and durable medical equipment, prosthetics, orthotics, and supplies

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RAC-Initiated Medicare Prepayment Reviews Will Soon Begin.

(February 7, 2012): In recent years, physicians and other health care providers have faced a wide number of administrative actions and sanctions levied by contractors working for the Centers for Medicare and Medicaid Services (CMS). Zone Program Integrity Contractors (ZPICs) have subjected physician practices to Medicare prepayment reviews, postpayment audits, suspension and / or revocation

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Lose Your Appeal at Reconsideration? Consider an ALJ Hearing

(June 18, 2011): As a review of the last several quarters of Medicare appeals statistics reflects, an overwhelming percentage of Medicare providers appealing alleged overpayments through the Medicare administrative appeals process have chosen to “throw in the towel,” so to speak, when they have lost at the reconsideration level. As you will recall, at the

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ZPIC Participation in ALJ Hearings is Increasing

(February 12, 2011): Over the last year, we have noted an important trend when representing Medicare providers in post-payment overpayment cases at the Administrative Law Judge (ALJ) level of appeal. Medicare contractors are actively attending and participating in many ALJ hearings. In fact, it is now common for a Zone Program Integrity Contractor (ZPIC) to

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Region B RAC CGI Announces that it will Begin Review of Eighteen Projects that Involve Medical Necessity

(August 25, 2010): CGI Technologies and Solutions, Inc., (CGI), has announced it will immediately begin reviews on 18 newly approved projects that involve the medical necessity of selected inpatient DRG payments. A complete list of the “issues” currently being examined by CGI can be found on its website. Recovery Audit Contractors (RACs), such as CGI,

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A Look at RACs — Part III: What Medicare Providers Know about RAC Audit Recoupment Rules.

(July 2, 2010): The Centers for Medicare and Medicaid Services (CMS) audit program involving Recovery Audit Contractors (RACs) is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on

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A Look at RACs — Part II: How Should Physicians and Other Providers Respond to a RAC Audit?

(June 29, 2010): In Part I of this series, we reacquainted you with the design and purpose of the now permanent Recovery Audit Contractor (RAC) Program. Although RACs largely focused on inpatient care during CMS’ demonstration program, RACs are a real threat to small providers that don’t have the intensive compliance programs in place that

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RAC Audits of Physician Practices, Home Health, Hospice, and DME Providers, are Expected to Increase.

(June 25, 2010): The purpose of this series of articles is to assess the Recovery Audit Contractor (RAC) Program from the perspective of physicians, home health, hospice, durable medical equipment (DME) providers, and other relatively small Medicare providers. As many non-hospital providers will acknowledge, early cries of wolf by law firms and consultants did a

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Is a ZPIC Tougher than a RAC or PSC When Conducting Medicare Audits?

(March 25, 2010): The Recovery Audit Contractor (RAC) program is an integral part of the Centers for Medicare & Medicaid Services’ (CMS’) “benefit integrity” efforts which seek to identify and recoup alleged overpayments paid to Medicare providers. Similarly, Program SafeGuard Contractors (PSCs) have been actively auditing Medicare providers and suppliers around the country. While the

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