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| Nancy Hirschl, CCS |
Lori Brocato |
There is good news and bad news when it comes to recovery audit contractor (RAC) appeals. The good news is they are delayed and we all have more time to prepare. The bad news is that when they come, they are likely to resemble a tsunami; flooding our HIM departments, pounding the shores of case management and clinical documentation teams, and drowning physician liaisons in paperwork.
The first in a 3-part series on RAC appeals, this month's column lays the foundation for understanding the appeal process. You'll receive helpful hints and practical advice on how to prepare your organization for the appeal process and ensure all systems are "go" when complex audits begin next year. When it comes to RAC appeals, you can either ride the waves or get stuck in the sand. This column will help you learn how to ride the waves, swim strong and win RAC appeals.
Laying Out the Landscape of RAC Appeals
During the demonstration project about one-third of the RAC reviews involved failed medical necessity and resulted in a lengthy appeals process. While there were also some DRG (coding) appeals, they didn't require the same levels of intense review nor were they as difficult to manage. A third type of appeal, one for automated denials, rarely occurred as most of these denials were for multiple units of service on the same day and practically undisputable.
Clearly, appeals for medical necessity reviews are the toughest and demand the most resources to win. In an earlier column, we laid the groundwork for understanding these complex appeals. This month, we'll revisit the process in more detail.
Tips to Win the Appeals Game
1. Submit the Discussion, Rebuttal and First Level of Appeal simultaneously within 15 days of receiving a negative determination or demand letter.
2. File your first level appeal within 30 days and you may be able to retain funds through at least the first two levels of the appeals process.
3. While you have up to 120 days to submit an appeal, prompt action puts you in a better position to win the appeal.
4. Really evaluate the likelihood of winning an appeal; if you can't justify your case, don't appeal.
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The First Steps of RAC Appeals
For each case the RAC reviews, a determination letter will be sent to you within 60 days (also called the Review Results, Demand Letter or Findings Letter). If a negative determination is made, the case should be reviewed by your RAC team and decision made to appeal or not appeal.
Not all cases will be appealed-nor should they be. In a future issue we'll provide specific suggestions on how to make this decision. Suffice to say cases with high dollar amounts are usually appealed.
The appeal process involves multiple steps, a lot of coordination and a plethora of internal and external resources. The first step is called the "Discussion Period." Discussion is with the RAC and generally occurs prior to the second step, the "Rebuttal Process." However, they can also happen at the same time. Here's the difference.
The Discussion Period begins with the receipt of a negative determination and ends 30 days later for complex reviews. Communication is with the RAC and should be focused on blatant oversights, errors or omissions on the part of the RAC. Your communication should be via mail or some other trackable form of communication. Some RACs prefer more informal communication such as phone calls and e-mail messages.
The Rebuttal Process also begins with receipt of a letter, but ends 15 days later. Communication is directly with the fiscal intermediary's Medicare Administrative Contractor (MAC) who is responsible to recoup overpayments for any case the RAC denies. These rebuttal procedures occur prior to the appeals process and are separate from the requirements of the limitation on recoupment. The rebuttal process gives you a vehicle to indicate why the proposed recoupment should not take place; and may help to preserve your cash during the formal appeals process.
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First Steps
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When they Occur
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What to Do
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Discussion Period
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Within 30 days of receiving a negative determination (demand letter).
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If you believe there was a blatant oversight on the part of the RAC, you have 30 days to communicate directly to the RAC. Communication can be via mail, fax, telephone or e-mail.
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Rebuttal Process
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Within 15 days or receiving a negative determination (demand letter).
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Communication occurs with the fiscal intermediary MAC. You are given an opportunity to rebut any proposed recoupment action and possibly avoid or delay cash loss.
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In a recent American Hospital Association (AHA) communication, it was recommended that providers submit first level appeal paperwork, discussion communication and a rebuttal letter all at the same time. While providers have a maximum of 120 days to submit a first level appeal, prompt action on all three levels is strongly recommended for the following reasons:
• It gets the process going and helps ensure deadlines are not missed.
• It places the organization in a much better position to win the appeal.
• If an appeal is filed with the FI/MAC within 30 days of the Demand Letter date, the organization can avoid or delay recoupment.
Beyond the First Steps
If the RAC continues to deny a case following the discussion and rebuttal phase, providers may continue to appeal the decision. Cases proceed through the same process for up to five levels of appeal. Providers may be able to retain the "cash in question" during this process as mentioned above, but interest can be charged back to the date of the Demand Letter if an appeal is not successful.
RAC appeals are a long, arduous process. However, if organizations have a clear understanding of the steps, know the deadlines, and are supported by RAC tracking technology tools, it is possible to keep your cash and stay dry during the tsunami!
Stay tuned next month for our second column focused on RAC appeals where we'll provide helpful hints on preparing your organization for 2010; when managing RAC appeals will be part of everyone's job description.
Lori Brocato is currently the revenue cycle management product manager for HealthPort. Nancy Hirschl is president and CEO of Hirschl and Associates, Laguna Niguel, CA.
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