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TIP OF THE WEEK FOR PHYSICIANS FACING RAC OR MEDICAL AUDITS: UNDERSTAND APPELLATE RIGHTS AND PROCEDURES AND APPEAL ALL ERRONEOUS ADVERSE FINDINGS

Recovery Audit Contractor (RAC) and private payer audits can be burdensome to physician practices. However, there are several things physicians can do to protect themselves before and during the audit process. Therefore, WhatleyKallas has compiled a "top ten" list of tips for physician practices facing RAC or other medical audits. We are highlighting one of these tips every week.  Click here for a link to the entire top ten list.

TIP NINE FOR PHYSICIANS FACING RAC OR MEDICAL AUDITS:  UNDERSTAND APPELLATE RIGHTS AND PROCEDURES AND APPEAL ALL ERRONEOUS ADVERSE FINDINGS

Physicians should understand a payer’s appeals procedures and should timely file any appeal of an erroneous audit finding.  Understanding a payer’s appeals procedures is important and can have a significant impact the ultimate result of the audit.  For example, the RAC program allows physicians 120 days to file a first level of appeal from a demand for overpayment (the “redetermination” level of appeal).   However, unless the first level of appeal is filed within 30 days, the physician will be subject to automatic recoupment of the amount demanded, even if an appeal is subsequently filed. Therefore, physicians who believe they have a strong case on appeal should consider filing it within 30 days to avoid recoupment.  As a further example, the RAC appeals process allows for informal discussions as a supplement to the formal appeals.  These informal discussions can be useful in having audit findings overturned without having to complete the formal appeals process.  Even when audit findings are not changed as a result of informal discussions, they can be useful in understanding the RAC contractor’s reasoning.  Physicians should be aware, however, that these informal discussions do not alter any of the deadlines for filing appeals.