Hanger is dedicated to helping you navigate the RAC audit process. The less time you spend dealing with paperwork, the more time you can spend taking care of the patients who need you.
Before you begin, review your audit correspondence to determine if you're dealing with a
Complex RAC Review or an
Automated RAC Review.
Then follow the step-by-step guide below to walk you through the process.
RAC Review Resources
The below documents can be used to appeal specific types of Medicare denials.
The below documents will help you complete your appeals forms accurately. Use the links provided to access the official forms directly on the Medicare website.
Hanger has compiled some information to help you through the RAC audit process.
The below documents offer a simple checklist of the step-by-step processes for Automated and Complex RAC Reviews
Healthcare practitioners always have good work to do. But too often, they spend a lot of time dealing with healthcare challenges like the RAC Audits.
By providing the tools and resources to navigate the RAC process, we hope to help streamline a challenging part of the business. A streamlined business is a more efficient business, and when the industry improves across the board, everyone benefits, especially patients.
Choose this step if the RAC review is requesting specific and additional information about the claim currently under review.
You'll first want to identify the specific information being requested. Once you know what you're looking for, review the Medicare LCD for the coverage guidelines for the services under review. Collect the relevant documents from the patient record that satisfy the RAC request and document the provision of, and medical necessity for, the services being reviewed.
More than one patient may be included in the RAC request. For each patient, you'll want to create a separate and individual RAC File with a copy of all information received from and sent to Medicare. This can include (but isn't limited to) signed and dated progress notes and measurement forms from the patient record related to the services provided; initial or dispensing order, and detailed written order; proof of delivery; and a CMN or Certifying Statement where applicable.
For each patient and date of service, you'll need to request documentation from other healthcare providers involved in the patient's care. Per Medicare, this documentation (defined as not just physician's office records but may also include “records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc.”) must be included in the medical record.
Clinical notes and medical records from the referring physician, operative reports, progress or clinical notes from a surgeon or other healthcare provider, hospital records and therapy records should all be included.
If you like, you can write a separate statement to clarify or support any of the documentation you've gathered, to help explain the path of the patient's care.
Keep in mind this letter isn't meant to take the place of official documentation. The only documentation that will be considered is signed and dated documentation that was in the file
on or before the date of service.
Bundle the documentation for each patient separately, along with the pull list requested in the RAC request. The RAC request should provide the address and/or fax number for records submission.
All documentation must be submitted to the RAC within 45 days of the date of the RAC request.
You'll receive the response from the RAC within 60 days of your submission. The determination could go in one of two ways:
1) If the RAC decides in your favor, congratulations! You're done. 2) If the RAC decides that all or part of the claim was paid incorrectly, it will refer the claim to your DME MAC for collection.
The RAC may determine that all or part of the claim was paid incorrectly.
DO NOT refund based solely on this letter. An overpayment demand letter from the DME MAC will follow shortly with further instructions.
The Review Results Letter will offer the option to enter into a “Discussion Period” with the RAC, if you want to provide further information to support the service billed.
Note that the Discussion Period is
NOT part of the appeals process. This is an independent opportunity to refute the RAC’s findings. If you receive an unfavorable response during the Discussion Period but fail to submit a timely Redetermination request, you may not appeal the results of the Discussion Period.
You must make your Discussion Period request in writing within 30 days of receiving the RAC Review Results Letter. Include evidence to support why you feel the services provided were properly coded and correctly billed, and should therefore be covered by Medicare. The Results Letter will provide you with instructions on where to request a Discussion Period.
It may take the RAC up to 60 days to review your Discussion Period submission and make its determination. Once the RAC makes its determination, you will receive a RAC Review Results Letter. The Letter will be clearly marked with the name of the RAC.
If the RAC upholds its decision, they will refer the claim to the DME MAC. You will receive an overpayment demand letter from the DME MAC shortly.
Good work. We were happy to help you.
The DME MAC Demand Letter lists the specific claims and claim lines that the RAC has reported as overpaid, though it may not mention or reference the RAC. Carefully review the Demand Letter and attached report to determine which patients, codes and dates of service are involved. Note that more than one patient may be included on the attached overpayment report.
Refunding should only be your first option if the overpayment determination is clearly correct, or if you are unable to submit a Redetermination Request within 30 days.
If you receive a RAC Review Results Letter that indicates you've been overpaid but don't receive the DME MAC Demand Letter within five business days of the Results Letter, contact the DME MAC for instructions.
Choose this step if Medicare has denied your claim and has begun the process of recouping payment for services provided.
Review the details related to the specific reason or reasons for the denial. Check the relevant patient records that address these reasons.
From here, you need to figure out if the overpayment determination is clearly correct or not. If it is, submit your refund. If not, it's time to file a Redetermination Request.
Refunds must be made within 30 days of the date of the Demand Letter, whether or not you agree with the RAC's determination. If you can't make the refund in a timely manner, Medicare will offset any claim payments associated with the Tax ID number under which your office operates on the 31st day.
You can delay refunds and offsets by submitting a Redetermination request within 30 days of the date of the Demand Letter.
Review the documentation you have on hand and determine if you believe you billed correctly. If so, you must submit a Redetermination request within 30 days of the date of the Demand Letter. Are you able to do so?
Submit the Redetermination request to the DME MAC using the address provided in the RAC letter or Demand Letter.
Appealing within 30 days will put the overpayment on hold. However, interest will be charged if the appeals outcome is not in your favor. A failure to either appeal or refund within 30 days will cause the overpayment to be recouped through claim offsets.
For each patient included on the overpayment report, create a separate and individual RAC file with a copy of all information received from and sent to Medicare. This includes but isn’t limited to signed and dated progress notes and measurement forms related to the services provided; the initial or dispensing order, and detailed written order; proof of delivery; CMN or Certifying Statement; and all relevant documentation from allied healthcare providers.
In the event that the denial is based on a misapplication of the Medicare LCD, the reference document for the appeal should be a copy of the Medicare LCD with specific reference to the clause or specifics of the regulation.
You have 120 days after the date of the RAC Letter to submit your Redetermination. However, recoupment will begin on the 31st day from the date of that letter.
DO NOT submit your appeal or refund to the RAC. The Demand Letter includes instructions for both processes.
Once the DME MAC reviews your Redetermination request, you will receive a letter that explains the outcome. If the DME MAC rules in your favor, congratulations! You’re done.
If the outcome is not in your favor, you can choose to proceed to the second level of appeal (called Reconsideration) or you can submit the refund if you requested Redetermination within 30 days of the initial Demand Letter. If you've already refunded, then no further steps are necessary. You're all done.
Be as clear and specific as possible with any and all information you provide to support your claim for payment. Leave no stone unturned.
In some instances, the reason for denial from Medicare may change or expand to deny additional codes. It's important you clearly document this change in the Reconsideration request.
Once you've completed the Reconsideration form, submit it with supporting documentation to the QIC at the address given in the Redetermination letter. You must submit your Reconsideration within 180 days of receiving the Redetermination denial.
The QIC will make a determination and send you a letter. If the DME MAC decides in your favor, congratulations! You're all done.
If the Reconsideration request is not ruled in your favor, you can continue to appeal the RAC's decision by requesting an Administrative Law Judge Hearing (the third level of appeal) or you can submit the refund if you requested Redetermination within 30 days of the initial Demand Letter. If you've already refunded, then no further steps are necessary. You're all done.
The Reconsideration letter will contain instructions on where and when to submit your ALJ Hearing request. You'll need to complete the forms to request an ALJ, provide basic ALJ steps, and complete a simple overview and documentation support to submit for the ALJ. You must submit your ALJ request within 60 days of receiving the Reconsideration denial.
Note that new information
CANNOT be submitted at this stage. Your case must rely on documentation already provided at the Redetermination and Reconsideration levels of appeal.
A Federal Judge Clerk will contact you by fax or mail with information about your ALJ's date and time. You've got five days to respond and confirm; otherwise, the denial will be upheld.
Typically, the judge will call on the appointed day and time to review documentation and listen to your reasoning on why the denial should be overturned. This is a legal proceeding, so witnesses will be sworn in and testimonies will be recorded.
If you win the ALJ, congratulations! You've successfully advocated for your patient.
If the ALJ rules against you, the RAC process is exhausted. You can either appeal to the Medicare Appeals Council, or you can submit a refund. You can submit a refund if you requested Redetermination within 30 days of the initial Demand Letter. If you've already refunded, then no further steps are necessary. You're all done.
Should you choose to appeal to the Medicare Appeals Council, the ALJ Denial letter will provide details on the process to submit that appeal.
To overturn an ALJ, you must provide clear evidence showing that the ruling Judge made a mistake in applying the rule of law. It's not enough that you disagree with the decision.
Keep in mind that this level of appeal is under a public forum, which means the final decision is published and can be used to set precedent for future cases.
If you win the appeal, congratulations! You've successfully advocated for your patient.
If the Medicare Appeals Council rules against you and you don't want to appeal, the process is now exhausted. You can submit a refund if you requested Redetermination within 30 days of the initial Demand Letter. If you've already refunded, then no further steps are necessary. You're all done.
If you wish to appeal the Medicare Appeals Council's decision, you may request a judicial review in a Federal District Court.
If you wish to appeal an unfavorable appeal made by the Medicare Appeals Council, you may request a judicial review in Federal District Court. The Medicare Appeals Council decision will contain instructions for filing this fifth and final level of appeal.
Two notes: The amount of money being contested must be at least $1,400, and you must request the judicial review within 60 days of the Medicare Appeals Council Decision.
If the judicial review rules against you, you have exhausted your appeal options. You can submit a refund if you requested Redetermination within 30 days of the initial Demand Letter. If you've already refunded, then no further steps are necessary.
Consult your RAC Audit paperwork to determine how to submit your refund..
Once the DME MAC reviews your Redetermination request, you will receive a letter that explains the outcome. If the DME MAC rules in your favor, congratulations! You're done.