How to Build RAC-Proof Admission Screening Criteria

Medicare's Recovery Auditors (RACs) focus primarily on high-dollar, "wrong setting" denials for inpatient services, but many hospitals overlook this area when preparing for RAC audits.


A recent whitepaper from Craneware (pdf) said that although Medicare does not require hospitals to use published screening criteria for inpatients, a hospital's utilization management committee should address admission leveling criteria to meet Medicare regulations and, potentially, avoid RACs. Karen Bowden, author of the whitepaper, listed three main recommendations:

1. Adopt all procedures on published "inpatient-only" lists from Medicare, any other payor with a published inpatient-only list and inpatient lists published in proprietary screening criteria.

2. Develop hospital-specific leveling criteria to address the "gray areas" where some procedures are billed as inpatient and other times as outpatient.

3. Establish a well-defined, second-level review process by a case manager who reviews specific types of cases and ensures there are consistent leveling practices. This can provide hospitals with defensible practices that meet Medicare regulations.

More Articles on RACs:

Medicare RACs Can Now Request Twice as Many Claims

AHA: More Than 70% of Hospitals Successfully Appeal RAC Denials

How to Bill for Renal and Urinary Tract Disorders and Avoid RACs

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