Recovery Audit Contractor Program Essay

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Recovery Audit Program (RAC)
Christina W. Furbert
Devry University
HIT230 Health Insurance and
Reimbursement
Professor Ingram

Table of Contents
What is RAC?..............................................................................................................................................................3
What type of audits will the RAC program cover?.....................................................................................................3
What could happen if it is discovered by RAC that health care organization may be committing fraud? Is there an appeal …show more content…
Although RAC auditors can subject a review of a medical claim at any time , to minimize provider burden, Recovery Auditors may look back only three years from the date the claim was paid; however, recovery auditors are not be able to review claims paid prior to October 1, 2007. The RAC audits specifically aim to identify claims that have been paid incorrectly, either by over or under paying the claim.

What could happen if it is discovered by RAC that health care organization may be committing fraud? Is there an appeal process? RAC uses software to identify claims that may not meet Medicare regulations and policy requirements. When a claim appears to have been paid improperly, RAC will notify the provider and either request medical records or repayment. If the health care organization does not agree with the RAC decision then it has the right to an appeal. RAC has implemented a rigorous and tightly managed appeals process to ensure that the institution can take full advantage of the appeal as allowed under law. In the RAC program appeal process there are five levels of appeals. In each appeal level if the denial is upheld then the providers next option is to file to the next level of appeal. Within each level there is certain criterion that must be met. (MedFocus) 1. Redetermination appeal must be filed within 120 days of RAC decision, in this level additional documentation can be submitted. 2. Reconsideration-must
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