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).
To effectively and efficiently handle the appeals process, Twist recommended the following technique tips:
- Use medical necessity to support your dispute. "Physicians' intent is critical at this stage," said Twist. "Back that up with the clinical evidence."
- Bring to light any discrepancy with Medicare policy and procedure, and cite regulations when applicable. "You're going to have to prove that it was necessary and that the intent was there, and that you followed the guidelines," said Twist. "We had good results with this at the ALJ level."
- Keep all your deadlines and submit complete evidence. If you don't submit evidence by the second level, they do not have to introduce it into the ALJ process, so make sure you fix problems you uncover as you go, she said.
- Do not use template letters. Twist's hospital attempted to use them in the beginning and quickly realized this was not the way to go. Letters should be developed on a case-by-case basis.
- Assign one person in the department to take ownership of the process. It's not something that you can multiple people do.
James Carroll is associate editor for the HCPro Revenue Cycle Institute.