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Medical Group Management Association

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Medicare Recovery Audit Contractors FAQs

1. Will the RACs identify underpayments? If an underpayment is found, will my practice receive a payment? 

RACs will identify overpayments and underpayments. If A RAC finds both from a provider, it offsets the underpayment with the overpayment. If the RAC finds only an underpayment, it notifies the Medicare claims processing contractor (fiscal intermediary, carrier or Medicare Administrative Contractor), which will then proceed with the claim adjustment and payment to the provider. Review the Centers for Medicare & Medicaid Services (CMS) educational article SE0617.

2. Can we see a copy of a RAC request?

Yes. CMS has shared a sample RAC demand letter and a sample intent to refer letter.

3. Does the RAC limit on medical records apply per individual National Provider Identifier (NPI) or per group NPI?

The medical record limit is linked to the billing NPI number. If your practice is enrolled with Medicare and submits claims for all your practice’s physicians under its group NPI, then the RAC medical record limit is linked to your group NPI. 

4. Will the RAC's letter indicate the problem with a claim? For example, medical necessity or incorrect coding.

Yes. The RAC letters will contain detailed information, including:

  • The coverage, coding or payment policy that was violated
  • A reason for conducting the review
  • A description of the overpayment situation
  • Recommended corrective actions
  • An explanation of the provider’s right to submit a rebuttal statement prior to recoupment of any overpayment
  • An explanation of the procedures for recovery of overpayments
  • The provider’s right to request an extended repayment schedule
  • Information on the provider’s right to appeal
  • Other demand letter requirements for written notifications

5. If my practice appeals a RAC decision by Medicare, must we immediately make the correcting payment and wait for the decision on the appeal, or does the appeal delay the need to pay?

If your group appeals the decision within 30 calendar days of receiving a letter requesting overpayment, recoupment is halted. Regardless of whether you file an appeal, interest begins accruing 31 days from when your practice receives the overpayment letter, unless you have made full repayment. Practices have up to 120 days to file an initial appeal. Review the CMS educational article on RAC appeals.

6. If the provider wins an appeal, can the RAC or CMS appeal that decision?

No.

7. What software vendors do you recommend for tracking the record requests?

MGMA does not endorse vendors or products, but we encourage members to strongly consider EHR systems certified by the Certification Commission for Health Information Technology (CCHIT). You can see a list of CCHIT-certified products and their current certification level is available at www.cchit.org.

8. Where do we find approved issues for RAC review by CMS? 

You can find the approved issue for review for your contractor here:
Region C
Region D

9. Are time frames for levels of appeal in business or calendar days?

Calendar days.

10. What is the RAC in my state?

See the chart and find your contractor on MGMA's RAC Resource page.

11. Will RAC audit requests only come via letter, or will auditors show up in the hospital or medical practice?

The RACs will typically send letters to practices requesting medical records. Although the RACs have the authority to go to providers’ locations to view and copy the records, medical groups may refuse to allow access. A RAC would then need to make a written request for copies.

12. Will the RACs review Medicare Advantage (Part C) claims?

No, the RACs review Part A and Part B claims only.

13. Will the RACs review claims from private insurance carriers?

No, the RACs review Medicare Part A and Part B claims only.

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