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CMS Reports that Providers Are Winning a Large Percentage of Appeals

In its report, “The Medicare RAC Program: Update to the evaluation of the three-year demonstration,” the Centers for Medicare and Medicaid Services (CMS) reveals that providers have been winning more appeals since its last report in January 2009. The report first noted that the number of reported claims for appeal have decreased significantly since the January 2009 report. The decrease is due to a more accurate method of counting claims, i.e., claims are now counted only once regardless of how many levels of appeal the provider pursues. In addition, CMS removed claims from the category of “appealed” if the denial was reversed by the contractor after it received additional documentation from the provider.

CMS’s report also found that providers chose to appeal 12.7 percent (76,073) of the RAC determinations. Of those appealed claims, 64.4 percent were overturned on appeal.

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