Know Your Rights, Medicaid Providers! RACs Cannot Recoup Claims Paid Over 3 Years Ago

Undergoing a Medicaid audit can seem overwhelming, to say the least.  I mean, the Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) has these Recovery Audit Contractors (RACs) reviewing Medicaid claims going back years.  If you have to pull the DMA Clinical Policy from 2007 in order to determine your compliance then the RACs are going  back too far, right? There has to be a statute of limitations or statute of repose, right?

There is.

RACs are prohibited from identifying overpayments on claims more than 3 years from the date the claim was paid. There is also a hard look-back limit of October 1, 2007.

HOT TIP:  If you have a Tentative Notice of Overpayment, check the dates you were paid for the claims.

My question is: Who or What entity is supervising the RACs to ensure no claims are recouped from more than 3 years ago? If the provider does not know the 3 year limit, is the RAC self-enforcing itself? Well, at least everyone reading my blog is knowledgeable now.

Also, RACs must comply with all reopening regulations found in 42 C.F.R. 405.980 (2008) because, in essence, these RACs are reopening claims that already were authorized, paid for, and done.

The regulations require that if a RAC reopens a claim more than 1 year after it was paid, then the RAC must show good cause….AND….document such good cause.

How many providers have asked the RACs to show the documented good cause for claims paid over one year ago?

Now you know you can…and should!

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on April 26, 2013, in Division of Medical Assistance, Federal Law, Health Care Providers and Services, Legal Analysis, Legislation, Medicaid, Medicaid Audits, NC DHHS, North Carolina, RAC, Tentative Notices of Overpayment and tagged , , , , , , , . Bookmark the permalink. 7 Comments.

  1. I thought 42 C.F.R. 405.980 only applied to Medicare audits and not Medicaid audits.

  2. I don’t even know how I ended up here, but I thought this post was good. I don’t know who you are but definitely you’re going to a famous blogger if you aren’t already
    😉 Cheers!

  3. Charged with overpayment from SSH on health insurance they paid without my permission. Need help fighting this thank you Patricia Manns. If you can’t reach me by e mail could you please call me at 971 352 7273.

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