January 7, 2009

RAC Update: Only 7.6% of providers’ appeals were overturned — CMS

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Of the nearly 25 percent of appeals filed by providers during the RAC demonstration, only 7.6 percent were overturned on appeal.

 

In a report released last week by CMS, the updated information — primarily on Claim RACs — reveals that providers chose to appeal 22.5 percent of the RAC determinations and that of all the RAC overpayment determinations, only 7.6 percent were overturned on appeals. The information updates the Evaluation of the 3-Year Demonstration report released in July 2008 that included data through the end of the demonstration on March 27, 2008.

 

CMS reports that, overall, the updated data indicate that of all the RAC overpayment determinations (525,133), only 7.6 percent (40,115) were overturned on appeals as of August 31, 2008. As has been widely reported here and elsewhere, RACs succeeded in correcting more than $1.03 billion of Medicare improper payments. Approximately 96 percent of these improper payments were overpayments collected from providers, while the remaining 4 percent were underpayments repaid to providers.


Provider Appeals of RAC-Initiated Overpayments:

Cumulative through 8/31/08, Claim RACs Only


Claims with overpayment determinations

Claims appealed by provider (any level)

Claims with appeal decisions favorable to providers

Percentage of appealed claims with a decision in provider's favor

Percentage of claims overturned on appeal

525,133

118,051

40,115

34.0%

7.6%

 

Source: cms.hhs.gov/RAC/Downloads/AppealUpdatethrough83108ofRACEvalReport.pdf

 

CMS says it will continue to update this information on a regular basis until all appeals have completed the appeals system.

Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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