Medicare Denial and Appeal Management Process: Preparing for Appeals with the Recovery Audit Contractors (RAC) Improper Payment Determinations
The following PYA Alert is the third release in a series on the topic of Recovery Audit Contractors (RACs).
Over the course of the Recovery Audit Contractors demonstration project (RAC), which concluded in March of 2008, it was estimated that only 11.3% of improper payment determinations identified by the RAC were appealed. Essentially, a large percentage of RAC overpayment determinations went unquestioned. Was the low percentage of appeals filed by providers a reflection of correct improper payment determinations made by the RAC, or, more so indicative of ineffective Medicare denial and appeal management processes across many organizations?
For many providers, Medicare has represented only a small percentage of total denials. Denial management process issues may have therefore been less apparent or even gone unnoticed. With the RAC improper payment reviews coming to your state by 2010, facilities can anticipate a notable increase in Medicare denial activity. The time is now for your organization to thoroughly evaluate its existing denial management processes and begin to increase key stakeholders involvement. The main goal of this exercise should focus on the structure and effectiveness of these processes to address RAC improper payment determinations, as well as to ensure timely appeals.
Internal process review considerations should entail at a minimum:
- Ensuring appropriate involvement by key departments such as Compliance, Patient Financial Services, Patient Accounting, Health Information Management (HIM), Case Management, Quality Management, and/or others
- Identifying a centralized source to receive and coordinate timeliness of RAC record requests for complex reviews
- Identifying a centralized source to receive and respond to RAC notifications of improper payments
- Developing a Medicare Denial Tracking Log and consistent process for tracking of the status of RAC medical record requests, RAC response(s), the appeal process, appeal status, financial impact, and final outcome of the appeal
- Reviewing of departmental responsibilities in a Medicare appeals process based on the type of RAC determination(s):
- Coverage Determinations Denial
- Coding Determinations Denial
- Other Denials Determination
PYA’s Clinical Compliance’s team of case management and HIM professionals can assist your organization in its preparation to manage RAC improper payment determinations and resulting appeals processes. For more information about our RAC preparedness services, please contact the experts listed below at (800) 270-9629.
The information provided via PYA Alert, Tax Planning Alert, or Audit and Accounting Alert should not be construed as accounting, auditing, consulting, or legal advice on any specific facts or circumstances. The contents are intended for general information purposes only. Please contact us at (800) 270-9629 to discuss your specific situation or to discuss any specific questions you may have.
