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RAC Appeals & Risk Assessments

Background

In the Tax Relief and Health Care Act of 2006, Congress required a permanent and national Recovery Audit Contractor (RAC) program to be in place by January 1, 2010. The Centers for Medicare & Medicaid Services (CMS) awarded contracts to four permanent RACs designed to guard the Medicare Trust Fund.

CMS is required to actively review Medicare payments for services to determine accuracy and if errors are noted to pursue the collection of any payment that it determines was in error. Section 302 of the Tax Relief and Health Care Act of 2006 requires the Secretary of the Department of Health and Human Services (the Secretary) to utilize RACs under the Medicare Integrity Program to identify underpayments and overpayments and recoup overpayments under the Medicare program associated with services for which payment is made under part A or B of title XVIII of the Social Security Act.

RAC Risk Assessments

Only CMS approved audit issues can be reviewed by RACs. In an effort to reduce Medicare improper payments, RACs may attempt to identify incorrect payment amounts, non-covered services, incorrect coded services or duplicate services. When identifying improper payments, RACs may make one or more types of determinations.

Kraft Healthcare Consulting assists healthcare organizations by performing RAC Risk Assessments, which help identify the type of determination an auditor may make. RAC Risk Assessments are based on the CMS approved issues, along with topics that KHC has identified as areas of risk. Taking a comprehensive approach, we use our multi-disciplined RAC team to assist facilities during these evaluations, and make recommendations for improvements to particular areas for the implementation of RACs.

RAC Teams

All facilities should establish a RAC Team. RAC teams will manage RAC preparations and assist with response to the audits. They should include personnel from senior management, legal, compliance, HIM, finance, utilization and/or case management professionals, and a tactical team of HIM, compliance, utilization, case management and quality professionals.

By educating those to be impacted by RACs, errors are potentially eliminated and anxiety is greatly decreased. Kraft Healthcare Consulting will aid in the organization of these teams, provide training for the disciplines of the RAC program, and help establish the policies and procedures.

RAC Appeals Assistance

Since CMS affords every dissatisfied provider the opportunity to appeal the initial decision, Kraft Healthcare Consulting provides RAC Appeals Assistance. The appeals process includes five potential stages:

1) Re-determination to the Carrier or Fiscal Intermediary;
2) Reconsideration submitted to a Qualified Independent Contractor;
3) Appeal to an Administrative Law Judge;
4) Appeal to the Medicare Appeals Council; and
5) Appeal to Federal District Court.

Each level of appeal contains certain guidelines to which must be adhered. Failure to do so could result in the inability to continue the appeals process. Managing the appeals process for RAC audits often proves to be another critical challenge for most healthcare entities.

The professionals at Kraft Healthcare Consulting have worked on Medicare appeals, and are highly qualified to assist providers throughout this undertaking. We produce efficient and effective strategies in responding to Medicare appeals, monitor the overall movement through the appeals program, and establish tracking systems to monitor RAC findings and appeals.