Provider RAC appeals higher, CMS says in report update

Providers appealed 19.6 percent of Recovery Audit Contractor (RAC) overpayment determinations, vs. the 14 percent that CMS stated in its July report of the three-year demonstration program. The difference in appeals was reported by CMS in an update to its July report. The update includes appeal statistics through June 30, 2008, and the initial report only included appeal statistics through March 27, 2008. The update can be accessed here.

Additional statistical changes within the report update include:

• Number of claims with overpayment determinations: 525,133
• Number of claims where provider appealed (any level): 102,705
• Number of claims with appeal decision in provider’s favor: 35,819
• Percentage of appealed claims with a decision in provider’s favor: 34.9 percent
• Percentage of claims overturned on appeal: 6.8 percent

Also, CMS reported that an additional 1,607 claims (valued at $12 million) are pending at the third level of appeals. At the time when the report update was published, CMS was unable to determine the number of appeals pending at the first level, although the first-level of appeals should have been filed by July 1, 2008. For this reason, CMS will again update the report through the fall of 2008.