San Antonio RAC Information

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Health care providers that render services to Medicare recipients in San Antonio or elsewhere in Texas have likely heard about the nationwide rollout of the Recovery Audit Contractor (RAC) program. RACs are private contractors selected by the Centers for Medicare and Medicaid Services (CMS) to audit the billing and medical records of Medicare providers.

At Wachler & Associates, P.C., our team of experienced health law attorneys has represented clients in RAC audits and appeals during the demonstration period of the new program. With the nationwide expansion of the RAC permanent program, we now represent clients across the country, including clients in San Antonio and throughout Texas.

Our law firm continues to track new developments in the RAC program. The recent passage of the health care reform legislation has ushered in an expansion of the RAC program. Since January 1, 2011 the RAC program has been expanded beyond Medicare Parts A and B to Medicare Parts C and D. The health care reform legislation also expanded the RAC program to Medicaid and required each state to contract with a RAC by no later than December 31, 2010.

If you are being audited or have received an adverse determination in an audit that you would like to appeal, don't hesitate to contact us to have our lawyers take a close look at your case based on our extensive experience with the RAC audit process.

Effective now, Medicare providers in San Antonio and throughout Texas that serve Medicare recipients and bill the cost of services to Medicare are subject to audits by Connolly Consulting Associates, Inc., the RAC for Region C . RACs are paid on a contingency fee basis, earning a percentage of overpayments and underpayments it identifies. All providers should be prepared for the possibility that they will be audited, but the following provider types in particular should be aware:

• Hospitals and health systems
• Skilled nursing facilities (SNFs)
• Durable medical equipment (DME) providers
• Hospice and home health agency (HHA) providers
• Physicians and physician groups
• Ambulatory surgery centers (ASCs)
• Radiology providers and independent diagnostic testing facilities (IDTFs)

During the RAC demonstration program, hospitals and health systems received the strictest scrutiny. However, no health care provider, no matter how small, should leave itself unprepared for the possibility of a RAC audit. RACs will attempt to identify improper payments resulting from: erroneous payments, non-covered services, incorrectly coded services and duplicate services.

Providers should also be prepared for Zone Program Integrity Contractor (ZPIC) audits. ZPICs are CMS contractors that look for overpayments and potential fraud. For these audits, each state has been assigned to a different contractor. Texas is located in Zone 4 for ZPIC audits, with Health Integrity, LLC as its contractor.

If you are audited by a RAC and determined to be liable for alleged overpayments that were made to you by the Centers for Medicare and Medicaid Services (CMS), our attorneys can help you pursue an appeal. We are highly experienced with administrative appeals generally and specifically with appeals of RAC audits.

The RAC appeals process includes five stages: redetermination, reconsideration, an administrative law judge (ALJ) hearing, a Medicare Appeals Council (MAC) review and a right of appeal to the federal district court.

We have guided many clients through the appeals process and are familiar with the most effective strategies to help them minimize both their liability for repayment of Medicare funds and the costs involved in weathering the appeals process.

If you are facing a RAC audit, another Medicare audit such as a ZPIC audit, or any other type of third party payor audit in San Antonio, elsewhere in Texas or in any other part of the country, contact us to get one of our experienced lawyers working on your case.