San Francisco RAC Information

Responding to Audits of Medical Provider Records

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Are you a health care provider serving Medicare recipients in San Francisco or elsewhere in the Bay Area? Are you concerned about the potential impact of the expanded Recovery Audit Contractor (RAC) program on your financial security? Are you wondering what you will do if you end up needing to respond to a RAC audit?

At the law firm of Wachler & Associates, P.C., we have extensive experience representing medical providers in RAC audits and appeals in California and the other states that participated in the RAC demonstration program. Our firm is 100 percent devoted to health law, and our attorneys understand the unique pressures on health care providers. Contact us to discuss what we can do to help you deal with RAC audits.

Preparing for Increased Scrutiny Under the New Program

Any health care practitioner or organization that provides billed services to Medicare recipients is subject to audits carried out by RACs on behalf of the Centers for Medicare and Medicaid Services (CMS). Our firm is attentive to the developments in the RAC program. The recent passage of the health care reform legislation has expanded the RAC program beyond Medicare Parts A and B to Medicare Parts C and D since January 1, 2011. Health care reform also expanded the RAC program to Medicaid and required each state to contract with a RAC by December 31, 2010.

Now that the RAC permanent program is operational in all 50 states, all medical providers in San Francisco, throughout California and nationwide should be prepared for a RAC audit. The types of providers subject to RAC audits include:

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

In California, RAC audits will be carried out by HealthDataInsights, Inc., the RAC for Region D. HealthDataInsights, Inc. will be paid based on a percentage of all funds it successfully identifies as Medicare overpayments or underpayments. Since underpayments have only represented a small percentage of cases, the focus of RAC audits under the permanent program is expected to continue to be on overpayments, recovering money paid by CMS to medical providers. RACs will attempt to identify overpayments resulting from: improper payments, non-covered services, incorrectly coded services and duplicated 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. California is located in Zone 1 for ZPIC audits, with SafeGuard Services, LLC as its contractor.

Choosing the Appropriate RAC Appellate Strategy

We are available to guide clients through all aspects of the RAC audit process. However, we can offer particularly critical legal representation during appeals of adverse RAC determinations. The RAC appeals process has five stages, including redetermination, reconsideration, an administrative law judge (ALJ) hearing, a Medicare Appeals Council (MAC) review and an appeal in federal district court.

Our experienced lawyers are intimately familiar with administrative appeals and with the specific appeals procedures that will be used with respect to the RAC audit program.

We have a track record of helping clients in San Francisco, throughout California and nationwide pursue reversal of inaccurate and improper determinations during the appeals process. Our team will carefully advise you on the best strategies for focusing our efforts on the stages of the process most likely to result in success.

If you are facing a RAC audit, you are interested in appealing a Medicare overpayment demand resulting from an audit, or you are concerned about whether you are prepared for the possibility of an audit, don’t hesitate to contact us at Wachler & Associates, P.C. We also represent clients in other Medicare audits, such as ZPIC audits, and all types of third party payor audits.