The Centers for Medicare & Medicaid Services (CMS) has released appeals data for Medicare fee-for-service Recovery Audit Contractors (RACs). For claims originating in fiscal year 2011 (Oct. 1, 2010-Sept. 30, 2011), providers appealed 56,620 repayment demands, over 6.25 percent of the 903,372 claims with overpayment determinations. Of these, 24,548 (43.4 percent) were decided in providers’ favor. Approximately 2.7 percent of all claims with overpayment determinations were overturned on appeal.
Overpayment determinations made by automated review were more likely to be overturned (17,893 of 31,297) than overpayment determinations made by complex review (4,426 of 22,188); however, despite the lower number and reduced success of complex review audits, the total dollars overturned was much greater for complex reviews (nearly $30 million, vs. nearly $6 million for automated reviews).
The current numbers show that providers who appeal RAC overpayment determinations have a roughly 50/50 chance of winning their appeal. In comparison, according to “The Medicare Recovery Audit Contractor (RAC) Program: Update to the Evaluation of the 3-Year Demonstration,” during the RAC Demonstration 12.7 percent of determinations were appealed, 64.4 percent of which were decided in favor of the provider.