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Medicare and Medicaid Recovery Audit Contractors (RAC)

If your medical practice is being audited or reviewed by Medicare or Medicaid recovery audit contractor (RAC) you need to know that Medicare has a placed very specific protections for providers when undergoing the review process. We won't fully discuss all of those protections in this video but we will discuss what the main protections are that can be utilized when you first find out you're being audited. You will be able to use these protections to push back the auditor and level the playing field.

Below are main protections that your practice may be able to utilize if being audited:

  • RAC's are limited to a 3 year look back period -  they cannot go past 3 years billing history and if they do they need to have a very good reason to do so and must fall into the laws that Medicare has given them.
  • 45 day record limitation - this period is based on the region in which the RAC sits and whether it is Medicaid review or Medicare review.
  • A RAC is obligated to review and accept any extension requests that it receives from a provider - If it says you have two weeks to respond to a request the RAC doesn't necessarily have to grant your extension request but they have to accept it, review it and if they are denying it they have to put the denial in writing. This gives the provider a second avenue for appealing the RAC's decision;
  • RAC's must contact provider following additional documentation request - before the RAC denies the medical bills for failure to receive additional documentation they have to contact the provider at least one additional time after the original documentation request was submitted. This can be key if you receive a request, you don't comply with the time given by the RAC and you're not contacted a second time as a reminder.
  • Prior audit prohibitions - The RAC's are prohibited from reviewing any medical bills that were previously reviewed by another Medicare or Medicaid contractor. You do not have to go through the same medical bills that a previous Medicare or Medicaid contract reviewed. 

Find out more information about these protections and additional protections available to medical practices being audited by a RAC in Ilana Sable's book "A Physician's Guide to Increasing Revenue and Surviving Payor Scrutiny in the Reformed Health Care Market".

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