Blog

RAC investigations and Allegations of Professional Misconduct

Posted by Joseph D. Lento | Jan 02, 2023 | 0 Comments

Recovery Audit Contractor (RAC) investigations are intended to identify improper payments of medical bills. RAC audits apply only to Medicare and Medicaid transactions. The purpose of these investigations is to ensure the government is neither over- nor undercharged and to prevent fraud.

Conducted by third parties, RAC investigations may be automated or complex. The total number of audits has decreased since revisions to the program in 2018. Even with these changes, medical professionals should ensure their billing system abides by current laws.

RAC investigations, or audits, do not directly tie into medical licensing. If, however, an audit uncovers the existence of fraud, you or your office may be reported to your profession's state governing board.

History

Recovery Audit Contractor (RAC) investigations first went nationwide in 2010. Overly zealous enforcement of the program led to revisions in 2018. The original program put an onerous burden on medical providers and overwhelmed the appeals process.

The updated RAC investigations require fewer documents and allow for class-action settlements. Contractors are also limited to requesting fewer documents and fewer audits within certain time frames.

Innocent Fraud

Even if not intentional, you may be liable for fraud in medical billing after a RAC audit. Some of the most common types of unintentional or innocent fraud include:

  • Billing with an expired license
  • Lack of proper supervision or oversight, including failure to provide sufficient time to review bills and claims for errors
  • Billing patients for unused medication – e.g., a patient never picks up a medication, but your office still bills them
  • Billing for a missed appointment – One exception is if your office has a written policy about charging when patients do not provide sufficient notification (usually 24 hours)
  • Assumption of certain services – e.g., failure to communicate that a patient did not receive the usual treatment or certain parts of a treatment
  • Submitting multiple bills for the same service

Pennsylvania's Medicaid Fraud reporting page provides a good example of what actions may constitute medical fraud.

In some cases, a patient's improper behavior may also open up your office or yourself to allegations of fraud. When a patient lies about their eligibility or identity or sells their prescriptions to others, that person's behavior may affect medical professionals who offer treatment.

That your actions were well-meaning, such as providing needed medical care to someone using another person's card, does not act as a defense. RAC audits do not consider your motives, only the end result. If the end result is that you committed fraud, you may be facing suspension or revocation of your license.

Addressing Allegations of Fraud

If, after a RAC audit, you've been accused of professional misconduct, you need to be proactive in your defense. What you need to do to protect your reputation and career depends on your profession and your state's specific laws involving misconduct or fraud.

Defense attorney Joseph D. Lento has the experience and skills in licensing defense and disciplinary proceedings for healthcare professionals. If you've been accused of misconduct or fraud after a RAC investigation or audit, call (888) 535-3686 or go online now.

About the Author

Joseph D. Lento

"I pride myself on having heart and driving hard to get results!" Attorney Joseph D. Lento has unparalleled experience fighting for the futures of his professional clients in Pennsylvania, New Jersey, New York, and also nationwide. With unparalleled experience occupying several roles in the justice system outside of being an attorney, Joseph D. Lento can give you valuable behind-the-scenes insight as to what is happening during all phases of the legal process. Joseph D. Lento is licensed in Pennsylvania, New Jersey, and New York, and is admitted pro hac vice as needed nationwide. In the courtroom and in life, attorney Joseph D. Lento stands up when the bell rings!

Comments

There are no comments for this post. Be the first and Add your Comment below.

Leave a Comment

CONTACT US TODAY

Attorney Joseph D. Lento and the Lento Law Firm are committed to answering your questions about Physician License Defense, Nursing License Defense, Pharmacist License Defense, Psychologist and Psychiatrist License Defense, Dental License Defense, Chiropractic License Defense, Real Estate License Defense, Professional Counseling License Defense, and Other Professional Licenses law issues in Pennsylvania, New Jersey, and New York.
Attorney Joseph D. Lento will gladly discuss your case with you at your convenience. Contact him today to schedule an appointment.

This website was created only for general information purposes. It is not intended to be construed as legal advice for any situation. Only a direct consultation with a licensed Pennsylvania, New Jersey, and New York attorney can provide you with formal legal counsel based on the unique details surrounding your situation. The pages on this website may contain links and contact information for third party organizations - the Lento Law Firm does not necessarily endorse these organizations nor the materials contained on their website. In Pennsylvania, Attorney Joseph D. Lento represents clients throughout Pennsylvania's 67 counties, including, but not limited to Philadelphia, Allegheny, Berks, Bucks, Carbon, Chester, Dauphin, Delaware, Lancaster, Lehigh, Monroe, Montgomery, Northampton, Schuylkill, and York County. In New Jersey, attorney Joseph D. Lento represents clients throughout New Jersey's 21 counties: Atlantic, Bergen, Burlington, Camden, Cape May, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex, Union, and Warren County, In New York, Attorney Joseph D. Lento represents clients throughout New York's 62 counties. Outside of Pennsylvania, New Jersey, and New York, unless attorney Joseph D. Lento is admitted pro hac vice if needed, his assistance may not constitute legal advice or the practice of law. The decision to hire an attorney in Philadelphia, the Pennsylvania counties, New Jersey, New York, or nationwide should not be made solely on the strength of an advertisement. We invite you to contact the Lento Law Firm directly to inquire about our specific qualifications and experience. Communicating with the Lento Law Firm by email, phone, or fax does not create an attorney-client relationship. The Lento Law Firm will serve as your official legal counsel upon a formal agreement from both parties. Any information sent to the Lento Law Firm before an attorney-client relationship is made is done on a non-confidential basis.

Menu