Coalition to HHS: Fix the RAC Appeals Process


January 21, 2014

Coalition to HHS: Fix the RAC Appeals Process

ACHCI urges Congress to reform the RAC appeals process,
preserve Medicare’s top integrity program

Washington, D.C. – The American Coalition for Healthcare Claims Integrity today submitted the following statement regarding the decision by the Department of Health and Human Services (HHS) to no longer accept certain appeals of Recovery Audit Contractor (RAC) Program decisions. Citing a backlog of 357,000 existing cases, HHS said it will not accept RAC appeals from providers to administrative law judges (ALJ) – the third level of appeal – for up to two years.

“The ALJ is ripe for reform,” said coalition spokesperson Becky Reeves. “From inconsistency in deciding cases to now refusing to review RAC decisions that have already been upheld at two levels of appeal, the ALJ is jamming up the auditing process and undermining the RAC program overall. Recovery Auditors – which have an average accuracy rate of 95% according to an independent third party – comply with Medicare policy at every stage of an audit. The ALJ’s refusal to review appeals subverts established Medicare policy. Just last week, officials began cracking down on the ALJ for haphazardly granting disability benefits and draining the Social Security Trust Fund at a rapid pace. Our coalition encourages CMS to reevaluate its decision and introduce similar, long-term reforms to the RAC appeals process that would allow the ALJ to effectively manage incoming appeals. Providers and auditors can agree – this is not sustainable.

“In 2010, enlisted by Congress, RACs went to work on behalf of taxpayers and Medicare beneficiaries to recover misspent Medicare funds. Since then, RACs have returned over $7 billion to the Medicare Trust Fund – all while reviewing only 2% of medical records. Despite this success, CMS has appeased hospitals by suspending a large portion of RAC audits until March 31, 2014. In light of this ruling and the ongoing issues with the ALJ, our coalition urges lawmakers to oppose any efforts to further restrict the most effective integrity program in Medicare history. RACs are ready to get back to work.”

This statement was included in letters to members of the House and Senate. For more information, please visit: www.properpayments.com

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