Recovery Audit Contractor (RAC) & Medicaid Integrity Contractor (MIC) Audits and Appeals

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At King & Spalding, we are exceptionally well-positioned to partner with health care providers to manage effectively the multiple Recovery Audit Contractor (RAC) and Medicaid Integrity Contractor (MIC) audits, recoveries and appeals they will confront. We also recognize the critical importance of preparing for RAC and MIC audits and appeals.

Our Approach

King & Spalding pursues a multi-layered approach for working through RAC and MIC audits and appeals: preparedness, handling appeals, and counseling providers on audit findings. To facilitate preparedness, we focus on client education and knowledge development, such as developing policies and procedures for communication with government contractors and development of templates to use during the appeals process. Our strategy during the preparedness phase is to transition our expertise to our clients so that they can self-handle the majority of lower level appeals, including requests to Medicare Administrative Contractors (MACs) for redetermination, requests to Qualified Independent Contractors (QICs) for reconsideration, and hearings before administrative law judges (ALJs). We are available to assist with lower level appeals as needed. We are also effectively postured to assist with other more complex, higher level appeals before the Medicare Appeals Council and in federal district court.

With respect to MICs, we understand the contractor deployment progression across the country for all three categories of MICs: Review of Provider MICs, Audit MICs and Education MICs. We are experienced in understanding the important differences between the scope of Audit MIC versus RAC reviews, and we can therefore advise clients in formulating appropriate audit response and appeal strategies. We also have significant experience in state Medicaid reimbursement requirements and the unique appeal processes that must be navigated in the MIC arena which can be challenging, particularly for providers operating in multiple states.

We further recognize that it is crucial to advise and counsel our clients on how to address potential compliance issues identified in RAC audits as well as how to proactively identify and prevent future compliance issues. We assist clients in conducting self-audits and provide legal analyses and counsel clients on their potential liabilities and obligations based on the audit results.

Our Experience

The strengths of our healthcare practice fall into the core areas critical to RAC and MIC preparedness, appeals, and counseling:

The Government Contractor Landscape. We have a keen understanding of the new contractor landscape and are dedicated to tracking related developments as they evolve. In addition to regularly participating in RAC and Medicaid Integrity Group (MIG) outreach sessions, we also monitor contractor activities in every region to better assist our clients with national and multistate operations. Our proactive efforts and client engagements have enabled us to develop a strong track record of building effective working relationships with the contractors, and to move ahead in understanding the rules regarding the interaction between contractors and law enforcement.

Reimbursement Criteria and Reimbursement Litigation. King & Spalding’s reimbursement litigation team has unparalleled experience with mass reimbursement claims. The team is currently representing more than 900 hospitals in reimbursement appeals for several thousand fiscal years, with an aggregate amount in controversy of approximately $1 billion. Through our experience in managing mass reimbursement appeals, the firm has internally developed sophisticated systems and procedures for case management and tracking.

Experience with RAC Issues. We have a deep understanding of the issues on which RACs will focus, due in large part to our experience on current engagements. For instance, we have developed a detailed understanding of issues impacting “short stay” cases. We have worked in conjunction with industry experts to develop strategies to defend against these types of claims, and have worked with our clients to establish strong internal controls for inpatient medical necessity management, including appropriate admitting documentation and correct coding of claims. We also have experience with the feasibility of implementing a “case management” protocol.

State Medicaid Experience. We have handled numerous Medicaid appeals and related state court litigation for hospitals and other providers. We are well-versed in the administrative framework that must be navigated to successfully challenge a Medicaid agency’s attempt to refund or recoup past Medicaid reimbursements, and have vast experience managing the aggressive time frames associated with critical steps in the administrative appeal process.

Compliance and Regulatory Analysis. We have extensive experience in providing advice and counseling to healthcare industry clients regarding a wide range of regulatory issues, including fraud and abuse compliance, reimbursement compliance, HIPAA and similar state law compliance, and in many other substantive areas. We have created a wide range of compliance structures and specific tools for clients which are used to promote compliance, including the development of written standards, procedures and protocols, training content, and tailored reporting vehicles. Additionally, we have assisted our clients to identify the need for internal audits and reviews and well as to manage the results.

Fraud Enforcement. Because many government contractors, including RACs and MICs, are obligated to “report instances of potential fraud” and are encouraged to report other areas of concern to law enforcement, our fraud enforcement expertise is also crucial. We have a core team of partners and associates who have handled a variety of criminal and civil healthcare investigations, with particular experience in investigations and litigation under the federal False Claims Act. We also have significant experience in defending inquiries initiated by Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs), both of which are likely recipients of referrals from the RACs and MICs.

Government Contacts and Network. King & Spalding has enjoyed strong contacts with government officials resulting from the significant number of our lawyers with former government service, including service at key administrative and enforcement agencies in the healthcare industry such as the DOJ, the HHS Office of Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the Food and Drug Administration (FDA). In addition, King & Spalding has also developed contacts with government officials through law practice or bar activities. We work diligently to strengthen our relationships with key officials in these agencies during active cases and within other contexts, such as industry trade associations, and believe the firm maintains a favorable reputation within these agencies.

Sara Kay Wheeler 
T: +1 404 572 4685 ATLANTA
Mark D. Polston 
T: +1 202 626 5540 WASHINGTON, D.C.