medical audit advocacy

The PAI endorses the Fair Medical Audits Act of 2015, which was introduced by U.S. Representative George Holding (R-NC).  Supporting materials can be accessed below:

• HR 2568 (PDF)
• Summary of Provisions (PDF)
• Key Points (PDF)
• PAI Press Release  (PDF)
• Letter Urging Support (Word File)
• Flowchart depicting RAC Appeals Process (PDF)

About HR 2568

HR 2568 Would strengthen the program as follows:

• Make every stage of the audit process more transparent;
• Establish more rigorous qualifications for RAC officials performing claims reviews;
• Increase accountability of RACs for inaccurate findings;
• Establish incentives for RACs to educate providers on common mistakes in coding;
• Prohibit the claw back of alleged over-payments until after a decision at the ALJ level of appeal;
• Promote more targeted documentation requests by RACs;
• Require a sound extrapolation formula for determining over-payment amounts;
• Shorten the "look-back" period from 4 years to 2 years.

History of PAI Medical Audit Advocacy

PAI has worked for several years to secure fairer practices within the RAC audit program:

• Developed model legislation entitled the “The Fair Medical Audits Act of 2014;” 
•  Met with the United States Senate Finance Committee staff. 
• Submitted extensive comments to the federal Office of Medicare Hearings and Appeals (OMHA) regarding potential regulatory fixes to address issues contributing to the appeals backlog caused by the flawed RAC audit process.  Access the comment letter here.

PAIl will continue to support state medical associations' efforts to secure fairer audit practices in Medicaid and in the commercial insurance market through state legislative and regulatory initiatives.