Within ten business days of receiving a RAC claim overpayment notice under the Medicare program, a St. Clair Physician Adviser (PA) performs a comprehensive review of the clinical record documentation. Based upon that review, St. Clair recommends, with supporting clinical rationale, whether hospital should exercise its RAC discussion option, go directly to Medicare Appeal Level 1, or not exercise either of those options.

If the RAC overpayment notice is still outstanding after using or not the RAC discussion option, a St. Clair PA consultant will consider having the hospital query the admitting physician for additional clinical information which influenced the decision to admit the patient. Then, St. Clair will proceed with the first level and, if necessary, the second level of the Medicare appeal process. On Medicare Appeal Level 3, a St. Clair PA files the written brief and makes the verbal presentation of our clinical appeal rationale in "simple layman" terms to the Administrative Law Judge (ALJ) in the telephonic hearing. Our PA consultants have a 90+% success rate in having the ALJ objectively and fairly approve those client cases which we recommended appealing. St. Clair will assist a hospital client in preparing and presenting a Medicare fourth level appeal to the Appeals Council Review and, if denied, the fifth level appeal with the Federal District Court.

Under its global pricing approach for monthly admission medical necessity reviews on a "concurrent or Medicare pre-billing" basis, St. Clair handles, without any "ala carte" fee per referred claim, the RAC "Medicare Claim Overpayment’ reviews & appeals.