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Medical Necessity RAC Strategies

James Carroll, for HealthLeaders Media, September 29, 2010

Taylor suggests that, as the team members begin to build their response process, some of the questions they should be asking themselves at this point include:

  • Who in our organization "owns" RAC response? Since many departments will be involved in the process, who is ultimately accountable for project managing the process?
  • What is expected of each department involved in RAC response?
  • How will we gauge our level of success overall and at each step in our process?
  • How will we utilize the RAC response process to better identify trends and changes that could help prevent future denials?

Q: What should the prepared provider do in addition to what they've already done?

A:  While there may be some facilities that aren't currently up to speed in their processes, most providers have at least done some form of groundwork. These providers likely have a team and system in place; and if they do, the next best step is to test it out by running a few drills, Taylor says.

"Submit a few mock RAC medical record request letters to test the effectiveness of your team and process," he says. "Then identify any potential weaknesses in the process and correct them before the actual letters begin arriving."

Q: What are some potential pitfalls for providers with medical necessity?

A:  First, a comprehensive utilization review process is a prerequisite to a successful appeals process.

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