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Medical necessity and RAC tracking management best practices

Recovery Auditor Report, October 20, 2011

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The following a checklist of best practice techniques when it comes to medical necessity and RAC tracking management strategies provided by Stacey Levitt RN, MSN, CPC, senior administrative director of patient care management at Lenox Hill Hospital in New York City.

• Admit orders. While everyone has probably heard it before, be sure to look at your admission orders. If the admission order does not match the level of care provided, that’s a red flag. Does the order say “Admit to a floor?” Does it say “Admit to a service?” Does it say “Admit as inpatient?”
• Utilization review. Look at your utilization management team. Are there case managers reviewing all of your cases to see if they meet the criteria for admission, or does it need to be bumped up to a physician advisor?
• Clinical documentation improvement (CDI). Do you have a CDI program in place? Because that’s where you are going to ‘beef up’ the information in the charts that will actually support your admission.
• Audits. Audit your charts to verify the necessity of an admission and to identify potential denial vulnerabilities.
• ·Physician education.  Be sure to educate all of your physicians, starting with your residents.

This checklist was adapted from the HCPro audio conference, “Combat RAC Denials: Strategies for Successful Appeal.”

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