10/03/2024    Paul Kesselman, DPM

Recoupment and Recovery Audit Contract (RAC) Audits

There are several additional points one should
understand when it comes to RAC and TPE.
You are not being targeted, it is the code which
is being audited and you have been the "lucky" one
selected from a batch of several thousand claims.

Second and most important: A colleague from
another healthcare profession and I recently
commiserated on our experiences with unjustifiable
denials as a result of RAC audits. We have both
concluded that these judgements are stacked
against the provider because the financial health
of the RAC agency is wholly dependent on
recovering money.

Third: It also costs the RAC and other agencies
money to go after you. So if your documentation is
spot on, it is likely when your number is picked
again, they may take a pass.

When the RAC finds you at fault, we have found
that the first line appeals to the original payer
(redetermination) and second line appeals to the
QIC (reconsideration) are largely rubber stamps of
the RAC. Why? Because these agencies don't want to
slap each other in the face and admit they were
wrong.

Four: The third level of appeal (ALJ) is usually
fair and in the last several cases my colleague
and I have handled (separately) the government
agency often doesn't even bother to show up. In
many cases when they even bother to provide
evidence it is contrary to the evidence they
originally submitted. This almost always leads the
ALJ to vote in favor of the doctor (who is the
plaintiff) and the government is the defendant.

Five: ALJ hearings no longer take five years to
schedule. In most cases, the time from submitting
the ALJ application to the appeal is less than a
few months. The most recent ALJ hearing I attended
was last week and and it was scheduled a mere
three to four months ago.
Six: Many physicians have been successful in
representing themselves, especially if they know
the LCD and policy article well and your
documentation has been reviewed and found to be
acceptable by an expert. If this is for a
relatively small amount of money and only for a
few claims with no extrapolation, you may want to
explore going it alone (with perhaps just an
expert).

Last: The take home message on RAC and other
audits is to not take to shortcuts with your
documentation, know the policy well and fight
back! If you are not sure if your documentation
meets the policy, have an expert shore that up!

The gov't and insurance companies are trying to
intimidate you. Don't let that happen! The vast
majority of ALJ hearings are favorable to the
doctor! So if you think you have the correct
documentation, go for it!

Paul Kesselman, DPM, Oceanside, NY

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