Medicare RAC Program Overview

Summary

This webinar, hosted by WPS GHA and Performant Recovery, provided an overview of the Medicare Recovery Audit Contractor (RAC) program, focusing on ADR (Additional Documentation Request) letters, extensions, technical denials, record submission, and reimbursements.
Roxan Cookie, the main speaker, detailed the scope, mission, quality assurance processes, and practical steps for responding to RAC audits.
Key questions from providers regarding submission processes, audit selection criteria, and system improvements were answered.
Upcoming session (Part 2) is scheduled for 5/21, with registration opening soon; presentation slides and follow-up information will be sent to attendees.

Shortly – Alen: Email presentation slides to all attendees.
Shortly – Alen: Send "thank you for attending" email with a survey and information about contact hours.
Soon – Alen/WPS: Open registration for Part 2 of the RAC education series and distribute registration links.
As needed – All providers: Direct follow-up questions to [email protected], specifying that you attended today’s session for Roxan Cookie to respond.

RAC (Recovery Audit Contractor) program identifies improper Medicare payments (overpayments/underpayments) and is monitored for accuracy and quality by CMS.
Performance of RACs is closely monitored: must maintain a first-level MAC appeal overturn rate at or below 10% and a quality rating of 95% or better (current regions report 97.5–99% accuracy).
Audits are based on CMS-approved issues published on the Performant website; contractor operates in Regions 1, 2, and 5.

ADR letters are sent to request documentation for complex audits; each letter includes a unique ID and specific claims under review.
Providers must respond by the stated due date; extensions (typically 14 days) can be requested via customer service, with further extension possible upon explanation of circumstances.
Non-response leads to technical denials; after a technical denial, records must be submitted within 30 calendar days (no extensions granted).
It is vital to maintain up-to-date provider contact information and have internal processes for routing letters to the right department or individual.

Technical denials occur if ADR letters are not responded to by the deadline, potentially resulting in Medicare payment takeback.
Providers still have 30 days post-denial to submit records; failure to comply shifts resolution to the MAC appeal process.
Performant makes courtesy calls approximately 30 days after an ADR letter if records are outstanding, also allowing for extensions or letter re-issuance by fax (not email).

Each claim must be submitted as a separate, clearly bundled set of records with its own barcode sheet; do not staple, but attach with clips or rubber bands.
Submission options: electronically via esMD (preferred), by mail (paper/CD), or fax (recommended only for small volumes).
Submissions close to the deadline require a courtesy call to customer service to prevent technical denials.
Using esMD allows for faster, electronic record exchange and higher per-record reimbursement (up to $27); non-esMD maximum is $15 per record.
No provider invoicing required; Performant tracks and issues checks within 45 days; providers can request to have checks mailed to a different address.

Medical records must be submitted separately for each claim, not as one bulk package.
Providers should submit records even if corrections (e.g., coding) are anticipated; claims can be corrected after receipt of the demand letter.
Both facilities and physicians are subject to audits; selection is code-driven and not random or targeted.
ADR cycles operate on a 45-day basis, with a maximum of eight requests per 12 months per provider; not all providers will receive the maximum number.
Performant is developing an enhanced portal to allow record uploads and status checks, but no launch date is available yet.
Providers can check the portal for ADR letter mail dates and record receipt status.
Provider/sample selection is algorithm- and code-driven, based on high-error billing codes, and must be CMS approved.
Contact info updates and more detailed FAQs are available on the Performant RAC website.

Continue development of enhanced provider portal — Upgrades to allow record uploads, status checks, and letter access are underway due to provider demand, but no timeline has been promised.

Estimated launch date for the upgraded Performant portal remains pending; Performant to provide updates as available.
Further questions from attendees to be sent to [email protected], with responses coordinated by Roxan Cookie.