decisionhealth Newsletters, Part B News - 2009 Issue 9 (September)
CMS: RACs can't override LCDs unless decision is in your favor
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Article Overview
This article explains CMS guidance affecting Medicare claim review under local coverage determinations, with a focus on the authority of Recovery Audit Contractors and Medicare Administrative Contractors in complex review situations. It is relevant to billing, compliance, and revenue cycle staff who monitor coverage disputes, appeals risk, and contractor authority under Medicare program integrity guidance.
Why This Topic Matters
It helps readers understand how Medicare contractor review authority is described in CMS guidance and why that distinction matters for coverage disputes, payment integrity, and potential appeals.
Article Sections
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CMS guidance on contractor authority
Introduces CMS instructions affecting contractor review of claims under local coverage determinations and the broader Medicare program integrity context.
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RAC and MAC review authority
Summarizes the article’s discussion of how different contractor types relate to local coverage determinations during complex review.
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CMS perspective on future policy and review
Covers CMS comments about the expected frequency of contractor disagreement with coverage policies and the agency’s oversight position.
What You Will Learn
- How CMS frames contractor authority in relation to local coverage determinations
- Which types of Medicare contractors are discussed in the guidance
- What broader compliance concerns the article addresses in complex review situations
- How CMS oversight of coverage-policy disputes is described
Who Should Read This
- Medical coders
- Billing specialists
- Compliance staff
- Revenue cycle managers
- Healthcare attorneys
- Medicare providers
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