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Healthcare Defense RAC Audit Lawyers

June 30, 2020

The current regulatory environment promotes great scrutiny of healthcare providers. In as much as the Centers for Medicare and Medicaid Services review and deny inappropriately billed services, healthcare reform has implemented more programs and external contractors who scrutinize the claims of providers. Recovery Audit Contractors (RAC) are contractors who identify Medicare underpayments and overpayments and return the overpayments to the Medicare Trust Funds. They review all claims submitted in an attempt to identify any improper payments. They are highly motivated to identify all improper payments because their fees are on a contingency basis.

Medicare still pays huge sums of money in fraudulent claims despite its extensive nature and complex billing regulations. RAC helps the CMS to ensure participating providers obey the rules. Healthcare providers facing RAC audits expect to be accused of seeking overpayments from the CMS.

When facing a RAC audit, healthcare providers risk paying recoupments for overbilled amounts. The providers can face extra financial penalties, criminal prosecution, and loss of eligibility. Also, RACs pursue allegations of overpayments because of their compensation model and might at times assert that incorrect recoupments are due. Therefore, healthcare providers need to be cautious and strategic when facing a RAC audit.

There is an appeal process, but it is costly and involves taking your case to several audit entities and administrative bodies. The healthcare provider needs to be proactive to minimize the adverse effects of a RAC audit. Your proactive approach begins with hiring a healthcare defense RAC lawyer who can identify the fault in calculations. Also, the healthcare defense RAC audit lawyer ensures that necessary Medicare standards are implemented to your billings for review.

To properly understand the RAC audit process, you need to understand all its aspects, such as:


RAC audits are disruptive and invasive. The RACs can inspect billing records of up to three years for Medicaid and Medicare Part A and B. For large healthcare providers, the three year billing period can mean thousands of documents for review.


RACs, give priority to uncovering overpayments and not to identify underpayments. This is despite the stated policy of CMS’s recovery program of identifying both underpayments and overpayments. RACs prioritize exposing overpayments during the audit process because of the contingency-fee compensation structure of CMS. The structure gives RACs financial incentives to claim the most substantial net overpayment.

The RAC Audit Process

RACs rely on human auditors and technological resources to carry out the audit process. Both are prone to error, and as a result, you cannot assume that the RAC process is just and fair. Before questioning the methods or conclusions of a RAC auditor, you need to have tangible reasons to back your claims. Therefore, healthcare providers need to engage the services of healthcare defense RAC audit lawyers to be able to spot any flaws and to communicate effectively about the faults in the process.

Application of Billing Standards

At times, RAC auditors apply incorrect billing standards to federal health programs. The auditors seek recoupments on outdated billing standards instead of applying billing regulations when healthcare providers bill the federal government. This brings the need for you to review all audit determinations. Your team of healthcare defense RAC audit lawyers can help in the review process and identify any irregularities.

Appeal Process

You need to put in place a proactive approach before and during a RAC audit. Prevention of an unfavorable verdict is better and cheap and eliminates the possibility of going through the complex appeal process. In case the circumstances force you to file an appeal, you need to do so within the stipulated deadline. Filing an appeal quickly helps in avoiding paying recoupments that are not due.

Given that you can determine the outcome of a RAC audit, you must try and influence the process. This will help in preventing the auditors from making unjustified conclusions to increase liability. Accountability in the RAC audit process is vital and is a crucial aspect that an experienced healthcare defense RAC audit lawyer can help you seek. Your healthcare defense RAC audit lawyer represents you in RAC audits and appeals to help you understand the process. Also, through their expertise and advice, they help you avoid payment of excessive recoupments and to maintain eligibility.



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