​​Jackson Davis HealthCare

​RAC Audit Appeals | ZPIC Audit Appeals | UPIC Audit Appeals
(303) 586-5003 or support@jdhcare.com

Medicare RAC Appeals / Medicare Shadow Audits

Since the initiation of the RAC program almost 10 years ago, Jackson Davis professionals have worked with providers nationwide to appeal and win 1,000s of RAC audit and ZPIC audit denials.  NO ONE will work harder or give you a better chance to win than Jackson Davis… and we prove it every single day!

Our professionals have challenged RAC audit and ZPIC audit results through every step of the Medicare appeals process and our record and reputation is unparalleled.  Time and again we have assisted providers in building solid Medicare audit defense cases for Redetermination / Reconsideration and successfully defended providers at ALJ hearings.  We are a passionate provider advocate and believe 100% that Medicare coverage criteria rules-the-day.  A sample of our top Medicare audit defense focus areas includes:

  • DME supplies (billing and medical necessity)
  • Emergency Room visit criteria and CPT code selection
  • Facet Joint Injections
  • Home Health Visits & Admissions
  • Hospice admissions (medical necessity – Part A & GIP)
  • Inpatient Rehabilitation Facility admissions
  • Lumbar Spinal Fusion
  • Major Joint Replacement (hips & knees)
  • One-Day Stays (chest pain, heart failure, syncope, etc.)
  • Outpatient physical therapy visits & KX modifier
  • PCI / ICD / Pacemakers (surgical procedures in wrong setting)
  • Physician E&M coding (99211 - 99215, 99223 and 99233)
  • Portable Radiology visits & billing
  • Skilled Nursing Facility admissions (Part A & Part B)
  • Use of modifier 25
  • Wound care clinic and procedure billing

Overview of a Winning RAC Appeals Strategy

With the Medicare RAC audit program being in full force nationwide, providers are tackling RAC audit denials and setting in motion a series of processes to successfully address RAC appeals.  Defending Medicare auditor denials, avoiding potential CMS fraud allegations and holding on to hard earned cash reserves are all critical.

… Several U.S. courts have held that a provider's adherence to Medicare coverage criteria trumps all in the evaluation of claim denials.  In fact, the courts have held that - when Medicare coverage criteria exists for a given focus area - CMS MUST use the payment criteria when evaluating claims for payment.  Nothing speaks louder in the Medicare appeals process than providers that painstakingly tie Medicare coverage 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 Medicare coverage criteria is a guaranteed approach to facilitating potential Medicare fraud investigations.

… 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 can be extremely difficult to add supporting documentation to a case under appeal and being heard by an ALJ.  When completing RAC appeals and "mock medicare 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.

… Remember, an Administrative Law Judge hearing and the Medicare Appeals Council review are the last 2 administrative steps in the Medicare appeals process.  The Medicare Appeals Council relies heavily on Medicare coverage criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.

Medicare RAC Appeals - Denials & Overpayment Determination

Jackson Davis works directly with providers and partners with leading Medicare law firms to build winning Medicare appeals cases and reduce the anxiety of potential Medicare fraud allegations.  The following information MUST be included with your request for all Medicare Appeals - RAC appeals, ZPIC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.

This is a great overview of the process by CMS [click here]:

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 Medicare's 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 Audit Overpayment Determinations

CMS Transmittal 141 specifically addresses a diverse range of Medicare appeals issues and discusses revisions to the Medicare appeals process.   Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted recovery auditors.  In summary, time frames relating to the filing of appeals during the first 2 steps of the Medicare appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration).  However, in order to stop the automated recoupment of overpayments, providers MUST file Medicare appeals within 30 days for redetermination and within 60 days for reconsideration.