"All the administrators should be comfortable with the criteria for inpatient or outpatient admissions," says Bowden.
- Review all RAC decisions. You should also keep in mind that each RAC decision should be reviewed by your team to determine if the RAC decision should be appealed. You need key measure to appeal a denial, Bowden says, and if you are appealing every decision with the same criteria set it will help.
"If the staff is too lax on these criteria or too aggressive, then you'll lose [the appeal]. Case managers need sensible criteria that define this area well for consistency, so if the RAC finds a 'wrong setting' denial the facility can defend it," explains Bowden.
Bowden also recommends building your criteria and then sharing it with your commercial payors for instant feedback. "Showing how other payers are looking at this can also be useful in your defense," she says.
With millions at stake for these RAC denials, establishing a simple set of criterion for everyone to work from is one quick and easy New Year's Resolution that every hospital and health system can tackle to make to 2011 a very prosperous New Year.
Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.