Audit Team Lead – Timothy E. Allen | Former Special Agent (U.S. Secret Service & DOJ-OIG)
Former Federal Agents Offering Medicare RAC Audit Defense Nationwide
For healthcare providers that rely on Medicare reimbursements to run their businesses and pay their employees, few events are more nerve-racking than receiving notice of a RAC audit in the mail. Recovery audit contractors (RACs) are private companies that work with the Centers for Medicare and Medicaid Services (CMS) to scrutinize Medicare-participating providers’ billing practices, pursue recoupments, and impose other penalties when warranted.
Even if your practice is fully Medicare-compliant, facing a RAC audit can still present significant risks. There are a couple of reasons why. First, RACs are financially incentivized to “uncover” overpayments from Medicare. Simply put, the more they recover for CMS, the more they get paid. Second, while RAC auditors are supposed to be experts in Medicare billing compliance, mistakes during RAC audits are common, and these mistakes can lead to substantial unjustified liability.
We Provide RAC Audit Defense Services for All Medicare-Participating Healthcare Providers
We represent Medicare-participating providers nationwide during RAC audits. In doing so, we rely on extensive experience as former federal agents who previously oversaw Medicare fraud investigations and assisted with the prosecution of other types of healthcare fraud cases. As a result of this experience, we are intimately familiar with the Medicare billing rules and regulations, and this allows us to both independently evaluate our clients’ Medicare compliance efforts and deal with RAC auditors effectively on our clients’ behalf.
Our Medicare RAC audit defense practice is nationwide in scope. As a result, we represent physician practices, clinics, hospitals, laboratories, pharmacies, and other clients during audits conducted by all five of CMS’s recovery audit contractors. As of March 2023, the RACs are:
- Performant Recovery Inc. – Performant Recovery Inc. is the RAC auditor for CMS Regions 1 and 2. It is also the RAC auditor for durable medical equipment (DME) and home health/hospice companies nationwide (Region 5). CMS Regions 1 and 2 cover most of the northeastern and central United States.
- Cotiviti, LLC – Cotiviti, LLC is the RAC auditor for CMS Region 3, which encompasses the southeastern United States.
- Cotiviti GOV Services – Cotiviti GOV Services is the RAC auditor for CMS Region 4, which covers the western United States as well as Alaska and Hawaii.
As CMS explains, “RACs review claims on a post-payment basis. The RACs detect and correct past improper payments so that CMS and [other authorities] can implement actions that will prevent future improper payments.” While RACs are supposed to identify both overpayments and underpayments, as a practical matter Medicare audits almost always focus on identifying provider mistakes that justify demands for recoupment. At Corporate Investigation Consulting, we have a proven track record of helping providers avoid unnecessary liability during RAC audits, and we work with RAC auditors on behalf of our clients to help ensure that our clients do not face recoupments (or other risks) unnecessarily.
Put our highly experienced team on your side
Roger Bach
Former Special Agent (OIG)
Timothy E. Allen
Former Senior Special Agent U.S. Secret Service
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Maura Kelley
Former Special Agent (FBI)
Ray Yuen
Former Supervisory Special Agent (FBI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Marquis D. Pickett
Special Agent U.S. Secret Service (ret.)
Understanding the Scope (and Risks) of a RAC Audit
When auditing Medicare-participating providers’ billing histories, RACs have substantial authority to examine providers’ records for numerous potential violations. While RACs are only authorized to examine the “Approved RAC Topics” designated by CMS, there are currently more than 175 approved topics—and many of them are extremely broad.
As a result, when facing a RAC audit, one of the first challenges providers face is simply determining where their risks lie—and what the RAC’s auditors are (and aren’t) authorized to review. This is where having in-depth knowledge of the Medicare rules and regulations comes into play, and it is one of the first areas in which we are able to add significant value for our healthcare clients.
By getting involved in our clients’ RAC audits early, we are able to help ensure that auditors only review the records they are authorized to review. We are also able to step in and address any other issues with the auditors’ methods and practices. Ensuring that the scope of the audit remains appropriately limited reduces both the costs and risks involved, and challenging inappropriate auditing methods and practices ensures that our clients are not penalized unfairly.
How We Help Our Clients Avoid Unnecessary Recoupments (and Other Consequences) During Medicare RAC Audits
When engaged to provide Medicare RAC audit defense services, these are just some of the ways we help protect our clients. When you choose Corporate Investigation Consulting to oversee your healthcare practice or business’s RAC audit, our former federal agents will also:
1. Conduct a Comprehensive Internal Medicare Billing Compliance Assessment
Before the RAC conducts its audit, our former federal agents will conduct a comprehensive internal Medicare billing compliance audit focused on the Approved RAC Topics. This way, we will know what (if anything) the RAC’s auditors are going to find.
If your healthcare practice or business’s Medicare billings are fully compliant, we can use the documentation we collect and generate during our internal assessment to demonstrate compliance and steer the audit toward an efficient result. If there are issues that need to be addressed, knowing what these issues are will allow us to address them in the most effective way possible.
2. Intervene and Take Control of the Audit Process
If a healthcare provider or business is not careful, its RAC audit can quickly get out of hand. Our former federal agents intervene and take control of the audit process to ensure that this does not happen. We will deal with the RAC’s auditors directly, oversee their efforts to ensure that they do not overreach, and immediately step in to address any other efforts to use unfair methods or practices.
3. Challenge Flawed Assumptions and Conclusions
As we mentioned above, RAC auditors make mistakes. If left unaddressed, these mistakes can lead to unjustified recoupment demands and other penalties. In addition to stepping in to address auditors’ use of unfair methods and practices, we also step in to challenge flawed assumptions and conclusions, and we work hard to ensure that our clients are not left in the position of needing to file an appeal.
4. Work to Proactively Resolve Any Medicare Billing Compliance Issues
If our clients have Medicare billing compliance issues that they need to address, we work to help our clients address these issues proactively—before they lead to unnecessary consequences. While many healthcare providers and business owners assume that a “wait and see” approach will be the most cost-effective, this generally is not the case, as allowing a RAC to “uncover” a compliance failure is far more likely to lead to serious consequences.
5. Implement Compliance Improvements and Identify Next Steps
Along with providing Medicare RAC audit defense services, we also provide comprehensive healthcare billing compliance services to all types of healthcare providers and other Medicare-participating businesses (i.e., DMEs). If necessary, we can help you implement compliance improvements to avoid unnecessary consequences during future RAC audits. We can also provide guidance on next steps for matters such as appealing the outcome of a RAC audit, and we can assist with preparing for a follow-on healthcare fraud investigation as well.
FAQs: Avoiding Recoupments During a Medicare RAC Audit
What triggers a RAC audit?
In most cases, RAC audits are triggered by apparent Medicare billing mistakes. If an automated review of a Medicare-participating provider’s or business’s billings raises red flags under CMS’s billing rules or regulations, this can trigger an intensive and exhaustive review. However, just because you are facing a RAC audit, this does not necessarily mean that your practice or business has improperly billed Medicare. RAC audits are often unjustified; and, in many cases, targeted providers and businesses will be able to avoid recoupments and other penalties entirely.
How do I prepare for a RAC audit?
A key step when preparing for a RAC audit is to conduct an internal Medicare billing compliance assessment. This assessment should focus specifically on the current Approved RAC Topics—which are the areas of compliance that RACs are authorized to review. Once you know what (if anything) the RAC’s auditors are going to find, then you can formulate and execute a sound defense strategy.
How far back can RAC audits go?
RAC audits can typically go back three years. This three-year “lookback” period runs from the date a claim is paid. RACs can request a longer lookback period in some cases.
Can I appeal the outcome of my RAC audit?
Appealing the outcome of a RAC audit is a multi-step process that starts with submitting a “request for redetermination” to the RAC itself. If this request is unsuccessful, then the next step is to submit a “request for reconsideration” to a Qualified Independent Contractor (QIC). After this, the next step is a hearing before an Administrative Law Judge (ALJ), then providers must go before a Medicare Appeals Counsel (MAC) before they finally get the right to challenge their RAC audit in court.
Can I handle a RAC audit on my own?
Due to the challenges and risks involved, we do not recommend that providers and business owners try to handle RAC audits on their own. Engaging a team of experienced outside consultants to help you avoid recoupments and other financial consequences can save money in the long run—and it can also help ensure that you do not suddenly and unexpectedly find yourself ensnared in a federal healthcare fraud investigation.
Speak with a Former Federal Agent About Your Medicare RAC Audit
Are you preparing to go through a RAC audit? If so, we encourage you to contact us for more information. To speak with a former federal agent in our Medicare RAC audit defense group in confidence, call 866-352-9324 or inquire online today.