The Medicare Recovery Audit Contractor (RAC) program is designed to ferret out incorrect payments to physicians, hospitals, and other health care professionals. An appeal to a RAC determination of overpayment is essentially the same as any other Medicare appeal. However, a RAC initial determination is not appealed to the RAC - rather it is appealed to the Medicare carrier, i.e., to TrailBlazer for Texas physicians.
So what is the first step? The Centers for Medicare & Medicaid Services offers the options below to physicians who disagree with the RAC's initial determination of overpayment.
Remember, one of a practice's best lines of defense for avoiding a RAC audit in the first place is a policy of regular coding and documentation audits, whether performed internally or by an outside consultant such as TMA Practice Consulting. Also, TMA's recorded one-hour webinar Avoiding RAC Audits discusses self-audits, what to do with your findings, and how to get buy-in for corrective actions.
Provider Options — RAC Overpayment Determination
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Discussion Period
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Rebuttal
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Redetermination
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Which option should I use?
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The discussion period gives you an opportunity to give the RAC more information showing why recoupment should not be initiated. It also gives the RAC an opportunity to explain the rationale for the overpayment decision. After reviewing the additional documentation you have submitted, the RAC could decide to reverse its decision. You will receive a letter will detailing the outcome of the discussion period.
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The rebuttal process gives you an opportunity to provide a statement and accompanying evidence indicating why the overpayment action will cause a financial hardship and should not take place. A rebuttal is not intended to be a review of supporting medical documentation or a disagreement with the overpayment decision. A rebuttal should not duplicate the redetermination process. (See 42 CFR 405.374-375)
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A redetermination is the first level of appeal. You may request a redetermination when you are dissatisfied with the overpayment decision. You must submit a redetermination within 30 days to prevent offset on day 41.
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Whom do I contact?
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Connolly Healthcare , the RAC for Texas
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TrailBlazer
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TrailBlazer
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Timeframe
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Day 1-40
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Day 1-15
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Day 1-120 - Must be submitted within 120 days of receipt of demand letter. To prevent offset on day 41, the redetermination must be filed within 30 days.
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Timeframe begins
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Automated review: Upon receipt of demand letter
Complex review: Upon receipt of review results letter
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Date of demand letter
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Upon receipt of demand letter
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Timeframe ends
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Day 40 (offset begins on day 41)
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Day 15
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Day 120
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Updated Aug. 12, 2011
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