Castle Rock Medical Group
Medicare RAC Appeals - Clinical, Compliance & Legal Resources
Unparalleled RAC Appeals Expertise = 91% FY 2009 RAC Appeals Success Rate

100% Unconditional Compliance Guarantee

This Unconditional Compliance Guarantee is offered for clients under professional services contracts for RAC audit medical reviews & assessments, RAC audit appeals and a wide range of similar CRMG compliance services.  Please contact us directly for contract terms & conditions at (303) 586-5003.

To speak directly with one of CRMG's experienced Medicare consultants or Medicare lawyers - or for questions regarding CMS efforts to stop Medicare fraud & abuse, CMS audits, CMS appeals, RAC audit clinical and billing assessments, Medicare RAC audit documentation, Medicare RAC appeals, RAC appeal attorneys or other Medicare compliance services - please contact us at (303) 586-5003 or support@racaudits.com.

Medicare RAC Appeals & Legal Services - 91% RAC Appeals Success

In order to effectively evaluate and consider the merits of each RAC appeals case, it is critical that providers and their respective legal counsel have an in-depth understanding of CMS evidence-based standard of care practices, CMS clinical & documentation payment criteria and CMS directives related to each RAC audits focus area.  CRMG leads the nation in understanding, documenting and applying CMS payment criteria for cases being considered for RAC audits and RAC appeals.

Medicare RAC Appeals - CRMG Process & Overview 

Medicare RAC audit appeals are won or lost with clinical documentation that clearly, concisely and unambiguously incorporates required CMS payment criteria.  Whether the focus area is One Day stays for cardiac-related diagnoses, Inpatient Rehabilitation Facility (IRF) admissions, PCI / implantable cardioverter defibrillators (ICDs), Emergency Room visits with modifier 25, excisional debridement documentation or any other focus area - CMS payment criteria is the single best foundation for winning appeals.

The following is an overview of CRMG's 5 step Medicare RAC appeals process:

1)  Step 1 - CMS Criteria-Based Case Review

Castle Rock Medical Group physicians, nurses, billing compliance professionals and legal services staff will evaluate each denial / overpayment determination case and compare the underlying documentation to required CMS payment criteria.  CMS criteria-based case reviews includes the evaluation of underlying clinical considerations, supporting medical records documentation, CMS evidence-based payment criteria and estimated financial impact.

2)  Step 2 - Prepare RAC Appeals & CMS Criteria-Based Case Summary

Based upon the outcome of the CMS criteria-based case review, we prepare all medical records, required CMS supporting documentation and a RAC appeals criteria-based case summary to accompany the submission to the Medicare Administrative Contractor (MAC).

3)  Step 3 - Submit RAC Appeals & Required Documentation

Submit all required CMS documentation to the Medicare Administrative Contractor and coordinate with provider staff and selected legal counsel throughout the redetermination & reconsideration process (RAC appeals - stages 1 & 2).  RAC appeal will be filed within 30 days of denial in order to stop the recoupment process.

4)  Step 4 - Initiate Coordinate with Legal Counsel at Reconsideration
 
If the provider's appeal efforts are not initially successful in the redetermination stage, CRMG professionals will work collaboratively with select health law firms in each of the 4 RAC regions to most effectively and aggressively challenge RAC audits recoupment throughout the remaining steps of the RAC appeals process.

5)  Step 5 - Provide CMS Regulatory & Clinical Expert Testimony

If the provider's appeal efforts are not initially successful during the initial 2 stages, CRMG can provide a full range of expert regulatory & clinical testimony in support of a provider's adherence to CMS payment criteria at ALJ hearings and or subsequent judicial proceedings.

For questions regarding Medicare RAC appeals, CMS billing and clinical case reviews, proactive RAC audit medical assessments or recommended RAC appeals lawyers, please contact us directly at (303) 586-5003 or appeals@racaudits.com.

2010 RAC Audits & Appeals Guide

Castle Rock Medical Group physicians, nurses, billing compliance professionals, Medicare consultants and Medicare lawyers have compiled over 5,300 RAC supporting documents, 125,000 pages of RAC documentation, medical necessity and billing protocols and over 100,000 RAC issue-specific references.  Order your 2010 RAC Audit & Appeals Guide today at compliance@racaudits.com.

Medicare RAC Appeals - The RAC Audits Demonstration Project

For the most part, providers throughout the demonstration states were "blindsided" by the adoption of formal CMS payment criteria and have filed over 118,000 appeals to try to stop the enforcement of such provisions as part of their Conditions of Participation.  To date, the courts have sided with CMS and CMS has won over 66% of all RAC audit appeal cases.

Understanding CMS payment criteria, why RACs are winning and why providers have paid back $980M in California, New York and Florida is the most critical step in the RAC appeals process.  CRMG brings a multi-discipline solution to the RAC appeals challenge and no one has spent more time or effort in understanding the key RAC denial focus areas.  CRMG's board-certified physicians, nurses and billing compliance professionals have assisted over 300 health systems nationwide and we are at the forefront of both the RAC audits & RAC appeals process.

Medicare RAC Appeals / Denials / Overpayment Determination

The following information MUST be included with your request for all appeal levels:

Beneficiary name
Medicare Health Insurance Claim (HIC) Number
Specific service(s) and/or item(s) for which the redetermination / reconsideration is being requested
Specific date(s) of the service; and
Name and signature of the provider or the representative of the provider

First Level – Redetermination (Medicare Administrative Contractor)

Claim denials or overpayments must be initially reviewed (appealed) to the appropriate Medicare Administrative Contractor (MAC) by requesting a redetermination of the claim within 120 days of the RACs initial decision.  Medicare Administrative Contractors are required to respond to a provider’s request for redetermination within 60 days of receipt.

Second Level – Reconsideration (Qualified Independent Contractor)

If a provider is dissatisfied with the outcome of the Level 1 appeal or redetermination process, a request for “reconsideration” may be filed with the appropriate Qualified Independent Contractor (QIC) within 180 days of the redetermination.  Requests for reconsideration are required to be processed within 60 days by the QIC.

Third Level – Administrative Law Judge Hearing

If a provider is not satisfied with Level 2 and the result of reconsideration, a hearing before an Administrative Law Judge (ALJ) can be requested.  The amount in controversy must be a minimum of $120 and requests for a hearing from an ALJ must be received within 60 days of the provider’s notice of the reconsideration outcome.

Fourth Level – Medicare Appeals Council (MAC)

If the Level 3 appeal and decision by the ALJ is considered unfavorable by the provider, a fourth level appeal request may be filed with the Departmental Appeals Board (DAB) / Medicare Appeals Council (MAC).  Requests for a MAC review must be filed within 60 days of receipt of the ALJ’s decision.  The MAC must subsequently issue a determination within 90 days of the review.

Fifth Level – U.S. District Court Review

If the Level 4 decision of the MAC is deemed unfavorable to the provider, the final step in the appeals process is to file suit in U.S. District Court.  Requests must be filed within 60 days of the MACs decision and the amount in controversy must be at least $1,180.

CMS Transmittal 141 - Limitation on the Recoupment of Medicare RAC Audit Overpayment Determinations

CMS Transmittal 141 specifically addresses a diverse range of Medicare appeals issues and discusses revisions to the Medicare RAC appeals process.   Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted recovery auditors.