RAC Audits & RAC Appeals - Profile

Jackson Davis HealthCare provides the nation's leading solution for the submission of RAC appeals.  Our industry-leading clinical auditors, legal staff and Medicare compliance professionals work directly with the nation's best health law firms and provide an unmatched CMS auditing and legal services solution.

                Step 1 - CMS Criteria-Based Case Review
                Step 2 - Prepare RAC Appeals & Criteria-Based Case Summary
                Step 3 - Submit RAC Appeals for Redetermination
                Step 4 - Submit RAC Appeals for Reconsideration
                Step 5 - Provide ALJ Hearing Support - Regulatory & Clinical Expert Testimony

To speak directly with one of our experienced Medicare compliance professionals, CMS clinical auditors or Medicare lawyers - or for questions regarding Medicare audits, Medicaid audits, Medicare appeals, CMS Payment Criteria, CMS clinical audit assessments or other Medicare compliance related issues - please contact us directly at (303) 586-5003 or support@racaudits.com.

Turning the Page - The Winning RAC Appeals Strategy - 91% Success Rate

With the Medicare RAC audit program being in full force nationwide, providers are preparing for RAC audit denials and setting in motion a series of processes to successfully address RAC appeals.  Hospitals, physicians, physical therapists, DME suppliers and a full range of other healthcare providers are quickly and aggressively turning their focus to fighting & winning RAC appeals.  Defending Medicare or Medicaid auditor denials, avoiding potential CMS fraud allegations and holding on to hard earned cash reserves are all critical.

Based upon our work with providers facing CMS audits (PSC audits, ZPIC audits, RAC audits and MIC audits) and potential Medicare fraud implications, the 4 most frequently asked questions are (1) how do we keep our money, (2) how do we stop CMS audits and denials in the future, (2) how do we win current RAC appeals, and (3) how do we stop CMS audit outcomes from turning into Medicare fraud allegations.

Within the RAC Appeals section we address a wide range of issues and strategies to consider when initiating the Medicare appeals process.  Most importantly, however, we simply can't emphasize enough the challenges to winning RAC appeals and the very real possibility of RAC audit outcomes becoming potential Medicare fraud issues.  Here are a handful of things to consider when tackling RAC appeals:

1)  CMS Payment Criteria will give you the winning hand

Several U.S. courts have held that a provider's adherence to CMS Payment Criteria trumps all in the evaluation of claim denials.  In fact, the courts have held that - when CMS payment criteria exists for a given focus area - CMS MUST use the payment criteria when evaluating claims for payment.

2)  Develop CMS Criteria-Based Case Summaries for all "winnable" RAC appeals

Nothing speaks louder in the Medicare or Medicaid appeals process than providers that painstakingly tie CMS Payment Criteria to medical records documentation and present an evidence-based argument for payment.  On the other hand, using the "appeal everything" strategy and not making internal operational changes to adhere to CMS Payment Criteria is a guaranteed approach to facilitating potential Medicare or Medicaid fraud investigations.

3)  Submit all required documentation during the first 2 stages of the RAC appeals process
 
It is critical that you file all the supporting documentation relating to a given case no later than Stage II - Reconsideration.  After this stage, it is extremely difficult to add supporting documentation to a case under appeal.  When completing RAC appeals and "mock audits" with providers across-the-country, we have found a number of hybrid medical record structures and significant challenges to submitting medical record documentation for review.

4)  Focus on adhering to CMS Payment Criteria and winning your RAC appeals

Remember, the Medicare Appeals Council is the last administrative step in the Medicare appeals process.  The Medicare Appeals Council relies heavily on CMS payment criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.

CMS / Medicare Appeals Resources

The RAC appeals can be challenging and may expose the provider to a wide range of Medicare fraud related issues.  Please see the RAC Appeals section for further information and guidance relating to recommended appeals work plan components.  The following are Medicare appeals documents highlighted on the cms.hhs.gov website:

                        RAC Appeals - The Medicare Appeals Brochure
                        RAC Appeals - Appeals Process Diagram
                        RAC Appeals - Limitation on Recoupment
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RAC Audits & RAC Appeals - Recommended Medicare Lawyers

The RAC appeals process can be extremely costly and the timeliness of CMS recoupment is a major challenge.  In addition, the ever-present issues relating to potential Medicare fraud allegations can be very serious.

Knowledgeable, independent health law firms and internal legal counsel representatives play vital roles in the completion of proactive CMS medical review assessments & the submission of RAC appeals.  In addition, our experienced Medicare compliance professionals, CMS clinical auditors and Medicare legal support staff emphasize a multi-disciplinary approach to addressing RAC appeals.  We can assist in providing a full range of RAC appeals submission efforts as well as providing expert testimony, clarifying regulatory requirements and contributing to extensive research efforts.

Jackson Davis HealthCare (formerly the Castle Rock Medical Group) has researched hundreds of health law firms nationwide and have developed working relationships with solely the best-of-the-best.  Our recommended health law firms and attorneys have hundreds of years of experience, they have assisted with over 10,000 Medicare appeals, Medicaid appeals and highly sensitive Medicare fraud & abuse related issues.  This very select group of attorneys and firms that can bring both a breadth of experience with the Medicare appeals process and a depth of CMS audit appeals knowledge to each client - without the additional cost.

To speak directly with one of our experienced Medicare compliance professionals, CMS clinical auditors or recommended Medicare attorneys - or for questions regarding Medicare audits, Medicare Appeals, CMS medical review assessments or other CMS compliance issues - please contact us directly at (303) 586-5003 or support@racaudits.com.