Case Management

RAC medical necessity audits are coming - are you ready to appeal?

Case Management Monthly, April 1, 2010

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The recovery audit contractors (RAC) are up and running. CMS is approving new audit topics all the time, and providers are starting to see more and more record requests and denial notifications.

Experts expect the RACs to begin auditing medical necessity this summer. Case managers may be asked to play a large role in appealing medical necessity denials because of their involvement in level-of-care determinations. To help case managers, we asked Medicare appeals experts to explain the case manager’s role in the appeals process.

When the RAC team receives a medical necessity denial, it will likely contact the case manager who ­initially reviewed the record, says Deborah K. Hale, CCS, president of Administrative Consultant Service, LLC, in Shawnee, OK. That case manager should review the case again to ensure that it meets screening criteria.

When reviewing the denial, case managers should be sure to use the screening criteria that were available on the date of the record in question. During the demonstration project, some claims were denied because the RAC used current screening criteria on a claim that was years old, Hale says.

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