decisionhealth Newsletters, Answer Books - 2009 Issue 6 (June)
Answer_Book / Recovery_Audit_Contractors / RAC reviews
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Article Overview
This article explains how Recovery Audit Contractors review Medicare claims and distinguishes the main review approaches used in auditing. It also notes the Medicare coverage-policy framework RACs follow, the provider response window for record requests, and the general appeal process available when an overpayment is identified. The content is aimed at readers who need a high-level understanding of Medicare audit procedures and contractor roles.
Why This Topic Matters
RAC activity can affect claim payment, documentation requests, and the timing of appeals. Understanding the review framework helps providers, billing staff, auditors, and compliance teams recognize the broader Medicare audit process without relying on contractor-specific billing rules.
Article Sections
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RAC reviews
Introduces Recovery Audit Contractors and outlines the two broad review approaches used in Medicare claim auditing.
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Medicare policy and coverage guidance
Describes the Medicare coverage-policy sources RACs must follow when evaluating claims and the role of other Medicare contractors.
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Provider response and appeals
Summarizes the provider timeline for responding to record requests and the general Medicare appeal path after an overpayment determination.
What You Will Learn
- The difference between the main types of RAC claim reviews
- How RACs fit within the broader Medicare coverage-policy framework
- What happens when a provider receives a records request or overpayment determination
- Which general Medicare appeal stages may follow a RAC review outcome
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Revenue cycle teams
- Healthcare auditors
- Providers and practice administrators
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