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Medical Necessity RAC Strategies

James Carroll, for HealthLeaders Media, September 29, 2010

After much anticipation, they've finally arrived. With the recent CMS approval of issues for DCS, the RAC for Region A, all four of the RACs are now actively reviewing claims for medical necessity validation. Now what?

HealthLeaders Media sat down with Michael Taylor, MD,vice president of clinical operations at Executive Health Resources in Newtown Square, PA. Taylor has extensive inpatient and outpatient experience in urban, rural, community and academic settings. Taylor has years of experience and expertise in guiding and assisting hospitals throughout all levels of the Medicare appeals process, including vast experience at the administrative law judge level.

Whether you are a provider that was prepared for the inevitable onset of medical necessity or you are now scrambling to catch up, there are undoubtedly some questions and concerns surrounding the medical necessity. Taylor spent a few minutes discussing strategies with us.

Q: What should the unprepared provider do?

A:  For the provider that perhaps hasn't done its due diligence in preparation for medical necessity audits, the first course of action should be building your RAC team, Taylor says. This team should include representatives from different departments including case management / utilization review, health information management, patient financial services, legal and compliance.

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