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RAC Appeals Process 'Broken,' AHA Says

Cheryl Clark, for HealthLeaders Media, January 16, 2014

"What these auditors seem to be doing is focusing on cases with claims for care provided during short lengths of stay, with the presumption being that if the length of stay was short, these patients probably didn't need to be inpatients in the first place. So therefore, they gamble that's the case and recommend denial."

He adds, "It's almost un-American the way this is being rolled out."

"Essentially, the RACs  are saying, 'you know, for all these short stay ones, we're going to assume that Medicare overpaid, and recommend denial, which moves a complex medical decision into a time-based criteria.'"

But in most of these cases, Hanks says, "when the patient presents, it's not clear what the clinical course is going to be, and where there's a substantial risk to the patient if (he or she is not admitted)."

Many of the denials his hospital is appealing have to do with patients whose care was billed as an inpatient but who in retrospect the auditors believe should have been on observation, a shorter, and less expensive category of outpatient as opposed to inpatient hospital care.

That means that patients and their families now have co-pays and deductibles, and don't qualify for Medicare coverage of many important types of post acute care services, such as a stay in a skilled nursing home.  And that hurts beneficiaries, Hanks says.

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2 comments on "RAC Appeals Process 'Broken,' AHA Says"


Thomas H (1/16/2014 at 1:48 PM)
This process is a nightmare I know I currently assist the RAC. Most of the high end personal dont have any clue of the process or procedures and seem to be very limited to being open to new structure or any ideas. I have been in the medical billing, collections, administrative field, etc for over 10 years now and the process needs to be fixed starting with the system upgrades and quicker transactions and either removing the sub contractors or requiring them to have a certain amount of personal. I have never been so frustrated or lost at certain times in my field until I ran into this process. I am greatful I have a job but I feel so unproductive because all the incorrect feedback and decision making. Well thats that I hope this process gets fixed quick for the better.

Karen Luther (1/16/2014 at 10:39 AM)
Thank you to the AHA for taking this stand!