Revenue Cycle

FAQ: Appealing automated reviews

Recovery Auditor Report, August 6, 2009

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.

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