Five Steps to Appeal RAC Denials Successfully

James Carroll, January 11, 2010

Appealing RAC denials is certainly a complex process, but providers can take certain steps to increase their success rate.

When chart requests come in, the appeals process begins, and it can last through up to seven different levels, with each level becoming more expensive to pursue. So determining the proper preemptive actions to take is vital.

"Success with RAC appeals is not about winning a single appeal, or even 10 appeals, or even 100 appeals," said Michael Taylor, MD, senior medical director of government and regulatory affairs at Executive Health Resources in Newtown Square, PA. "You can be extremely successful in your appeals, but if you can only appeal half your cases because of limitations in your human resources, you won't be successful overall in reclaiming the appropriate funds."

For an appeal to have a high likelihood of success, your argument must address three components, according to Taylor:

  • Clinical: You must have a strong medical necessity argument using evidence-based literature.

  • Compliance: You need to demonstrate a compliant process for certifying medical necessity.

  • Legal: You want to demonstrate, when applicable, that the RAC has not opined consistent with the Social Security Act.

And build your appeals with the Administrative Law Judge (ALJ) level in mind. "Start with your head there, and work toward it, it will save you a lot of work in the long run," said Tanja Twist MBA, HCM, director of patient financial services at Methodist Hospital of Southern California in Arcadia (CA).

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