Revenue Cycle

Appeals council issues a ?partially favorable? decision

Recovery Auditor Report, April 1, 2010

The Medicare Appeals Council has issued a decision on one of the many outstanding appeals from the RAC Demonstration Project. This is of particular interest because the RAC’s revised initial determination on one particular claim stated that the provider had received an overpayment for the inpatient services but the beneficiary met the criteria for outpatient observation. The Administrative Law Judge’s (ALJ) decision was "partially favorable" to the provider and it stated that payment should be made under Medicare Part B for those services that cannot be made under Medicare Part A. CMS went on to appeal the ALJ’s decision.

Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is an instructor for the Medicare Boot Camp – Hospital Version, and Medicare Boot Camp – Critical Access Hospital Version. This article first appeared in Medicare Weekly Update as a “note from the instructor.”  Continue reading Debbie Mackaman's note.

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