FAQ: Appealing automated reviews
The RAC Report, August 6, 2009
Want to receive articles like this one in your inbox? Subscribe to The RAC Report!
Q: Can we appeal a RAC automated audit that results in a denial?
A: Regardless of the type of RAC review, you may appeal a RAC denial or recoupment if you believe the denial is not warranted Many of the automated reviews focus on billing rules, such as maximum units per day, so even if additional units seem appropriate, billing rules reign.
However, it may be worthwhile to appeal a claim when the effective date of a rule causing the denial is different than the date services were rendered. For example, consider local and national coverage determinations. A recoupment today based on current guidelines may not have been in effect when the patient received the service. If you are aware of this date discrepancy, consider appealing and include in your appeal documentation the effective date of that medical policy.
Hospitals’ awareness of the importance for timely and comprehensive documentation (especially physician documentation) to prevent and overturn denials has escalated over the past few years. It is common today to find hospital's implementing in-hospital documentation programs. Those hospitals that have deployed such programs have found improved documentation compliance and are better equipped to provide a defensible response when reimbursement is challenged.
Editor’s note: Yvonne Focke, RN, BSN, MBA, director of revenue cycle and integrated care services at St. Elizabeth Healthcare in Kentucky answered this question. We would also like to take a moment to welcome Yvonne to the RAC Report Advisory Board.
Want to receive articles like this one in your inbox? Subscribe to The RAC Report!
Related Products
-
2010 RAC Track: Medicare Compliance Forum Audio Recording
On-demand audio recordings of the RAC track of HCPro Revenue Cycle Institute's popular Medicare Compliance Forum, held May...
-
Clinical Documentation Improvement
Hospitals are undoubtedly aware of how a quality clinical documentation improvement program can benefit their facility, but...
-
Short Stays: A Data Driven Approach to Medical Necessity
Join us for this 90-minute audio conference and learn how to take a data-driven approach to billing one-day and short stays...
-
Combat RAC Denials: Strategies for Successful Appeals
During this 90-minute audio conference, our speakers provide step-by-step procedures, timelines, tools, and best practices...
-
2010 Observation Services Track:
On-demand audio recordings of the Observation Services track of HCPro Revenue Cycle Institute's popular Medicare Compliance...
Most Popular
- Articles
-
- HIPAA Q&A: Flu shot requirement for hospital employees
- HealthDataInsights posts new issues for medical necessity claims
- New FAQ posted on storing laryngoscope blades
- Q&A: Incidental disclosures and patient privacy
- Sneak Peek: Effort underway to establish caseload benchmarks
- What does case-mix index mean to you?
- Tip: Perform your own internal investigation prior to government audit
- Tip of the Week: Treat faculty orientation like resident orientation
- Capturing all necessary codes for IUD insertion and removal can be challenging
- Topic: CMS, OESS post new security compliance review information, checklist
- E-mailed
-
- What does case-mix index mean to you?
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- HHS task force: Consider privacy, security with text messages
- HIPAA Q&A: Flu shot requirement for hospital employees
- Tip: Know the common bunionectomy procedure codes and how to use them
- Code changes should help ease the pain when coding for facet joint injections
- Documentation and coding for toxic metabolic encephalopathy
- News and briefs: UA study links lack of empathy in residents to long shifts
- OB services: Coding inside and outside of the package
- Correctly code for new cardiac, pulmonary rehab benefits
- Searched