Are providers winning RAC appeals?
A. Based upon the latest publicly available data, providers are winning approx. 35% of RAC appeals. Initially, demonstration state providers did prevail in a substantive portion of cases brought before the ALJ (level 3 of the appeals process). However, CMS has continued to force-the-issue around payment criteria and they have prevailed in 66% of all appeal cases. It is crucial to note that providers have challenged approx. than 22.5% of all RAC audit overpayment determinations (approx. 118,000 appeals out of 525,000 RAC claim denials). Out of the 118,000 RAC appeals to date, providers have prevailed in approx. 40,000 cases. As a result, CMS is prevailing in 93% of total claim denial cases. The bottom line – it is critical that providers consider the application of CMS Payment Criteria for all RAC appeals focus areas and diligently work toward the adoption of an evidence-based outcome clinical & reimbursement structure. The old days of arguing “my doc versus your doc” and leading with l
