Health Information Management

Tips for RAC appeal success

HIM-HIPAA Insider, September 7, 2010

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According to a July HCPro survey of approximately 500 healthcare providers, 56% have already received medical record requests and 40% have had money recouped by a RAC. As these numbers continue to grow, so will the percentage of providers who need to appeal RAC denials. Luckily, we have some tips and tools that might help providers formulate and win their appeals, courtesy of Tanja Twist, MBA, HCM, director of patient financial services at Methodist Hospital of Southern California in Arcadia, and Elizabeth Lamkin, MHA, an associate at Axcel Healthcare Group in Tampa, FL.

1. Remember the limitation on liability. “The limitation on liability is something that people have had great success with,” Twist said. It is explained in section 1879(a) of the Social Security Act. If applicable, you may want to include this in your appeal letters. “This basically says that the provider did not know or could not reasonably have been expected to know that payment would not be made for the service at the time that it was rendered,” she explained. Twist suggests using it to point out that a physician was acting in the best interest of the patient based on what he or she knew at the time.
2. Forget about your 10 extra days. Ten extra calendar days are added to all RAC appeal timelines, but Twist recommends forgetting about them instead of using them as a cushion. “As you are setting up your tracking and your response timelines, I really, really encourage you to forget that those exist,” she said. Why? Because if you wait until the very end to file an appeal and the mail is slow, the RAC may receive it but not enter it into its system in time, and its system could end up kicking out an automated retraction. “You could request that money back, but that’s just another step you’ll have to take,” Twist explained.
3. Take charge of correspondence. Simply put, you need to educate your mailroom, Lamkin said. “Anywhere that you’re getting mail in, make sure that everybody is on alert for demand letters. You don’t want to have any time lost; you just don’t have much leeway.” And don’t be afraid to test your system—send a fake letter and track it. “Find out how long it takes to get to the people that need it,” she said. You need to ensure your designated contact receives the letter in a timely fashion. After that, track how long it takes to get to your executive team in the facility so you know how to respond. And finally, make sure your RAC has your correct contact information. (Triple-check if you like. Providers have reported problems with this!) It may help to set up a separate post office box for your really important RAC documents, Lamkin said.
Editor’s note: This tip was adapted from an article in the September issue of Medical Records Briefing. Subscribers have access to the full article in their newsletter.

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