RAC Training: Outline of RAC Appeals Process


The RAC rebuttal is optional. We may not use this very often because we don't think the RACs are going to be highly amenable to changing their stance. But we do have this RAC rebuttal process so that within 15 days we can get back to the RAC and say, “No, you're wrong. This should have been paid. It was properly paid, et cetera.”

Now, if we don't bother with the zero level, we just jump into the standard Medicare appeals levels. The first level was simply a request for redetermination. Now, normally, we have a fairly long period to file that. But if you want to stop recoupment, you're going to have to do well than 30 days. Both at the first and second level you'll have to do within 30 days to stop any recoupment efforts.

Thus, you're going to have to be fairly quick, our expert mentioned in a RAC healthcare event. You're going to have to be on top of these things tracking what's going on. And just keep in mind, you could be dealing with hundreds if not thousands of cases. So everyone, just a word to the wise.

The rest of the appeals process, third level, administrative law judge, then up to the Medicare Appeals Council and then finally, fifth level, federal district court. Well, by the time you get to the fifth level, you're going to have to really seriously consider cost and benefit because it's going to expensive to go to court.

Mar 31, 2019
Kelly Dennis
Mar 31, 2019
Kelly Dennis
Mar 26, 2019
Duane C. Abbey

When is it worth appealing?

Does this process take a long time? Well, as you might imagine, if you really elongate each of the time periods out, you could be in the appeals process for years. And that's certainly not something what we want to do, particularly in the sense if we go all the way through this. At some point, they're going to recoup the money then we're going to be fighting to get it back.

Are you going to need outside assistance?

Well, in some cases yes, if you go up to the Appeals Council, the federal district court, yeah, you're going to want attorneys to be involved, our expert suggested in a health system conference. So yeah, there can be some significant expenses involved in this whole thing.

Can the RAC recoup the payment while we appeal?

Well, there are some places where they can and some places where they can't. At the first two levels, you're going to do most of your work.

If you get your appeals in within 30 days, then you can hold off on recoupment. But if you were not successful up through the second level, you'd have to take a deep breath to decide whether you want to continue and go to the third level.

RAC Training Tip: For those of you that are not into all of the Medicare manuals and transmittals and everything, please get Transmittal 141. It's Publication 100-06. This is one that you really should sit down and read because this is a relatively long transmittal that describes all of the things that are going on with RACs. This was set up to direct the RACs, what they could do, how they could do it, how the appeals process is supposed to work, et cetera. So please get that and read it.

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