Hospitals and Health Systems Subject to RAC Audits
The Recovery Audit Contractor (“RAC”) program will be operating nationwide by 2010. The Centers for Medicare and Medicaid Services (“CMS”) believes that the RACs in the nationwide permanent RAC program will initially focus review activities on hospitals and health systems. During the RAC demonstration program, 85 percent of all claim denials made by RACs involved inpatient hospital claims.
Although the areas that will be subject to review during the permanent RAC program cannot be predicted with certainty, reviewing the categories of claims denied during the RAC demonstration program (which are published as part of the RAC Demonstration Evaluation Report), and reviewing other CMS guidance (e.g., the annual OIG Work Plan document) can assist hospitals and health systems to determine potential areas of RAC scrutiny.
During the RAC demonstration program, many claim denials involved inpatient hospital services that were alleged to be medically unnecessary, and many other claim denials involved inpatient hospital services provided in the “wrong setting” (i.e., CMS believed the services could have been provided in a lesser care facility or as hospital outpatient services).
Wachler & Associates, P.C., has proven experience in the RAC audit and Medicare appeals process. During the RAC demonstration program, our firm successfully represented hospitals and health systems subject to RAC audits and claim denials. Additionally, attorneys at our firm are frequently asked to write and speak to professional and provider organizations regarding RAC audits and Medicare appeals. For example, our attorneys have been asked to write and speak to the organizations listed below, among others:
Publications
"The RACs are Coming - Are You Ready?" co-author Andrew B. Wachler, Esq., Member Briefing: American Health Lawyers Association Hospitals and Health Systems Practice Group, January 2009.
"RAC to the Future: What Can Medicare Providers and Suppliers Expect from the Recovery Audit Contractor Program?" co-author Andrew B. Wachler, Esq., The Health Lawyer, The ABA Health Law Section, Vol. 21, No. 2, December, 2008.
"The RACs Are Coming - Are You Ready?" co-author Andrew B. Wachler, Esq., The RAP Sheet, American Health Lawyers Association, Regulation, Accreditation and Payment Practice Group, December 2008.
"Recovery Audit Contractors and Medicare Audits: Successful Strategies for Preparing for and Defending Audits," co-author Andrew B. Wachler, Esq., Journal of Health Care Compliance, September-October, 2008.
"The Medicare Appeals Process and Strategies for Successful Appeals," co-author Andrew B. Wachler, Esq., American Health Lawyers Association, Physician Organizations, Vol. 10, Issue 1, Winter, 2007.
"Get Ready: The RACs May Be Nationwide Sooner Than Expected!" co-author Andrew B. Wachler, Esq., HCCA Compliance Today, 2007.
"The New Medicare Part A and Part B Appeals Process," co-author Andrew B. Wachler, Esq., Health Law Handbook 2006, Part I, Chapter I, 2006.
"The New Medicare Appeals Process," co-author Andrew B. Wachler, Esq., The Health Lawyer, The ABA Health Law Section, June 2005.
Speaking Engagements
"Building a RAC Shield: Best Practices in Preparedness & Case Studies of Success," The 4th Annual Hospital and Health System Financial Management Congress, Co-Presented with Susan Bihler, Director of Utilization Management at Florida Hospital, September 22, 2009.
"RACs: Appeals Strategies," Health Business Management Association (HBMA) 2009 Spring Education Conference, May 6, 2009 - May 8, 2009.
" RAC Audit Appeals- Strategies and Defenses for Overturning Hospital RAC Denials," National Healthcare Compliance Audioconference, May 5, 2009
"Ready or Not, Here They Come! Preparing for and Defending the RACS," (HCCA) 13th Annual Compliance Institute, April 26, 2009 - April 29, 2009.
Advanced Appeals Workshop, 2009 American Health Lawyers Association (AHLA) Institute on Medicare and Medicaid Payment Issues, March 25, 2009 - March 27, 2009.
"The Basics: How the RAC Appeals Process Works," National Medicare RAC Summit, March 5, 2009 - March 6, 2009.
"Recovery Audit Contractors and Medicare Audits," 2009 American Bar Association (ABA) Emerging Issues Conference, February 18, 2009 - February 20, 2009.
"Recovery Audit Contractors and Medicare Audits," 2009 AHLA Hospitals and Health Systems Law Institute, February 10, 2009 - February 11, 2009 (with representatives of CMS).
"Recovery Audit Contractors and Medicare Audits," 2009 AHLA Physicians and Physicians Organizations Law Institute, February 9, 2009 - February 10, 2009.
"Managing the Recovery Audit Contractor Review Process," World Research Group, December 8, 2008 - December 9, 2008.
Please click here for a more complete listing of our attorneys’ publications and speaking engagements.
The Importance of Compliance
Although hospitals and health systems cannot stop RAC audits from happening, they can immediately put systems in place for:
- Tracking record requests and timely responding;
- Implementing appropriate compliance programs (which would include monitoring your hospital’s admission and utilization review procedures); and
- Making efforts to understand the Medicare appeals process and available audit defenses.
Contact Us
Call us at 248-544-0888 or send us an e-mail to schedule a meeting to discuss your concerns with RACs or to discuss your other healthcare law-related needs.
