Audits and Recovery Auditors (RAC)

Prepare your practice for public and private insurer audits.

Understanding the RAC Program

CMS developed the RAC program to identify and recoup Medicare overpayments and underpayments that were not detected through existing error detection and prevention program efforts. The RAC program audits providers' fee for service claims on a post-payment basis as provided for in Section 306 of the Medicare Modernization Act of 2003.

Medical Record Guidelines

The medical records guidelines for RAC audits are as follows:

  • Claims are reviewed on a post-payment basis
  • RACs use the same Medicare policies as carriers, FIs and MACs (e.g., NCDs, LCDs, etc.).
  • There are two types of review: automated (no medical record) and complex (medical record required).
Medical Record Limits

The numbers of records physicians have to submit depends on the type of practice they belong to:

  • Less than 5: 10 medical records per 45 days per group taxpayer identification number
  • 6-24: 25 medical records per 45 days per group taxpayer identification number
  • 25-49: 40 medical records per 45 days per group taxpayer identification number
  • 50 or more: 50 medical records per 45 days per group taxpayer identification number
  • RACs must implement the look-back date of three years
  • RACs cannot review claims prior to October 1, 2007
RAC Contractors

RACs can only review claims for audit issues approved by CMS and each contractor has a list of issues posted on their website.

Region A:
Performant Recovery
333 North Canyons Parkway, Suite 100
Livermore, CA 94551
Phone: 1-866-201-0580
States: Vermont, Maine, Massachusetts, New York, Pennsylvania, New Hampshire, New Jersey, Connecticut, Rhode Island, Delaware, District of Columbia, and Maryland

Region B:
CGI Technologies and Solutions, Inc.
11325 Random Hills Road
Fairfax, VA 22030-6051
Phone: 1-877-316-7222
States: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky

Region C:
Connolly Consulting, Inc.
The Navy Yard Corporate Center
One Crescent Drive, Suite 300-A
Philadelphia, PA 19112
Phone: 1-866-360-2507
States: Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Tennessee, Mississippi, Georgia, Alabama, Florida, South Carolina, North Carolina, Virginia, and West Virginia

Region D:
HealthDataInsights, Inc.
7501 Trinity Peak Street, Suite 120
Las Vegas, NV 89128
Phone: 1-866-376-2319
States: Iowa, Missouri, Kansas, Nebraska, South Dakota, North Dakota, Wyoming, Montana, Idaho, Utah, Nevada, Arizona, California, Washington, Oregon, Alaska, and Hawaii

AAN Urges CMS to Rescind RAC E/M Audits

In a letter, the AAN expressed concern and opposition to CMS' decision to approve Connolly, Inc., the RAC for region C, to conduct limited audits for E/M services in physician offices. The Academy was joined in its opposition by several other medical societies representing cognitive specialists.

The AAN is actively monitoring this issue and will provide updates as they are available.

Private Insurer Audit Resources

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