Physicians and Physician Groups Subject to RAC and Medicare Audits
It is important for all Medicare providers and suppliers, including physicians and physician groups, to prepare for RAC audits. One important step to prepare for RAC audits is for Medicare providers and suppliers to identify potential areas of focus for the RAC auditors, in order to ensure that the providers and suppliers have adopted and implemented appropriate compliance plans.
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 providers to determine potential areas of RAC scrutiny. CMS has identified the following areas as areas for targeted review, among others:
- Place of service errors;
- Evaluation and Management (“E/M”) services; and
- “Incident to” billings.
Physicians and physician groups must prepare now for increased Medicare scrutiny of these types of claims, among others.
Wachler & Associates, P.C., has represented providers, suppliers and other healthcare entities subject to Medicare audits and claim denials for over 20 years. Some of our firm’s more recent Medicare appeals experience includes the following:
- Our firm defended a Medicare audit of a physician requesting that the provider repay over $2.3 million. As a result of the hearing, the overpayment demand was reduced to $89,000, or just 3.5 percent of the original request.
- Our firm defended a Medicare audit of a physician requesting that the provider repay the Medicare program over $200,000. As a result of the Administrative Law Judge hearing, the overpayment demand was reduced to $0.
- Our firm defended a Medicare audit of a physician requesting that the provider repay the Medicare program over $2.5 million. As a result of the Administrative Law Judge hearing, the overpayment demand was reduced to $0.
- Our firm represented a provider group faced with a Medicare audit requesting that the group repay the Medicare program over $850,000. Following the Administrative Law Judge hearing, the overpayment demand was reduced to only $68.
- Our firm represented a hospice entity, which had been subject to an audit of its services provided to 17 beneficiaries. In that case, we received 14 favorable decisions on the record, without even the need for a hearing.
- Our firm currently represents a large health system that was subject to RAC auditing during the RAC demonstration program. Of the appeals we have filed to date on behalf of this organization, our success rate approximates 90 percent.
- Our firm currently represents a hospice entity that was subject to pre-payment review. To date, our law firm has been successful to return over $4 million to the entity, with a high success rate. As a result of these successes, the hospice was removed from pre-payment review.
Attorneys at our firm are frequently asked to write and speak to physician 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
"Latest Developments Related to the Nationwide Expansion of the Recovery Audit Contractors," Michigan Bar Association Health Law Section, September 24, 2009.
"RACs and Medicare Audits & Appeals," American Society of Medical Association Counsel (ASMAC), September 17, 2009 - September 20, 2009.
"Recovery Audit Contractors & Medicare Audits: Compliance Tips & Successful Appeals Strategies," Healthcare Billing and Management Association, May 7, 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.
"Third Party payor Audits," American Society of Addiction Medicine, April 26, 2007 - April 29, 2007.
"The Medicare Appeals Process," 2007 American Health Lawyers Association (AHLA) Annual Physicians and Physicians Organizations Law Institute, 2007.
"The New Medicare Appeals Process," Annual Meeting of the American Academy of Ophthalmology, November 11, 2006 - November 24, 2006.
"The New Medicare Appeals Process," Annual Meeting of the Medical Group Management Association (MGMA), October 25, 2006.
"The New Medicare Appeals Process and Strategic Approaches to Medicare Audits," 2006 Annual American Health Lawyers Association (AHLA) Annual Physicians and Physicians Organizations Law Institute, August 2, 2006 - September 2, 2006.
"The New Medicare Appeals Process," Associated Professional Sleep Societies, June 2006.
"The New Medicare Appeals Process," Michigan Podiatric Association, March 2006.
"The New Medicare Appeals Process and Strategic Approaches to Medicare Audits," American Health Lawyers Association (AHLA) Annual Physicians and Physicians Organizations Law Institute, February 8, 2006 - February 9, 2006.
"Medicare Appeals, Exclusive Contracts, Compliance, Legal Risks of Facility Ownership, Society for Pain Practice Management," September 2005.
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.
