Jackson Davis HealthCare cited the following five issues to consider when pursuing an appeal against a recovery audit contractor's decision.
1. Cite CMS payment criteria. Adhering to CMS payment criteria "will give you the winning hand," Jackson Davis advised. These criteria are the strongest defense against a RAC. Several U.S. court decisions have held that CMS must use the payment criteria when evaluating claims for payment.
2. Develop case summaries based on CMS criteria. Providers should present an evidence-based argument for payment, using detailed case summaries tying CMS payment criteria to medical records documentation.
3. Don't just appeal everything. Using an indiscriminant "appeal everything" approach and not making internal operational changes to follow CMS payment criteria could well attract fraud investigations.
4. Submit all documentation by stage two of appeals. All documentation should be filed by stage two of the appeal process because after this stage, it is extremely difficult to file added documents.
5. Legal or procedural arguments don't work. When coming before the Medicare appeals council in the last administrative step in the Medicare appeals process, refrain from using legal or procedural arguments and rely on adherence to CMS payment criteria instead. The council's approach "has shown time and time again that legal or procedural arguments are extremely difficult to win," Jackson Davis said.
Learn more about Jackson Davis HealthCare.
Read more coverage of RACs:
- 10 Tips on Improving RAC Readiness From Kaiser's RAC Expert
- 18 Findings from the Latest AHA Survey on RAC Activity
- 6 RAC Issues For Hospitals in 2011
1. Cite CMS payment criteria. Adhering to CMS payment criteria "will give you the winning hand," Jackson Davis advised. These criteria are the strongest defense against a RAC. Several U.S. court decisions have held that CMS must use the payment criteria when evaluating claims for payment.
2. Develop case summaries based on CMS criteria. Providers should present an evidence-based argument for payment, using detailed case summaries tying CMS payment criteria to medical records documentation.
3. Don't just appeal everything. Using an indiscriminant "appeal everything" approach and not making internal operational changes to follow CMS payment criteria could well attract fraud investigations.
4. Submit all documentation by stage two of appeals. All documentation should be filed by stage two of the appeal process because after this stage, it is extremely difficult to file added documents.
5. Legal or procedural arguments don't work. When coming before the Medicare appeals council in the last administrative step in the Medicare appeals process, refrain from using legal or procedural arguments and rely on adherence to CMS payment criteria instead. The council's approach "has shown time and time again that legal or procedural arguments are extremely difficult to win," Jackson Davis said.
Learn more about Jackson Davis HealthCare.
Read more coverage of RACs:
- 10 Tips on Improving RAC Readiness From Kaiser's RAC Expert
- 18 Findings from the Latest AHA Survey on RAC Activity
- 6 RAC Issues For Hospitals in 2011