1. Never assume the RAC denial is accurate. In the RAC demonstration project, 64.4 percent of all appeals were decided in the provider’s favor. “If you believe you can defend how you billed a claim, then defend it by writing an appeal,” Ms. Bowden wrote.
2. Always meet appeal deadlines. You can stop automatic recoupment of payments by meeting the deadlines for appeals at the first and second levels. Any appeal that not is received by the 30th day at the first level of appeal or by the 60th day at the second level will result in recoupment.
3. Gear initial appeal for later appeals. New evidence cannot be presented at the administrative law judge level, where many appeals are won. That means the letter for the first level of appeal must summon your best arguments, even though most first-level appeals are lost. “Use the time and resources necessary to defend your position fully at the first level of appeal,” Ms. Bowden wrote. “The outline followed for the first level of appeal will be the defining argument presented to the ALJ.”
4. Document coding issues. If the appeal relates to a coding issue, attach all supporting documentation to defend the coded claim. Coding-related denials are usually related to documentation that does not support the coding, such as a major complication and comorbidity. It can also involve a coded procedure that was not supported or coding errors such as incorrect principal diagnosis sequencing, incorrect discharge disposition or incorrect code selection.
5. Don’t give up. “When filing a RAC appeal, you should be persistent,” Ms. Bowden wrote. If you believe you are right and have the evidence to support your argument, continue to escalate the appeal to higher levels if you are not initially successful.
Tips on writing the appeal letter
Ms. Bowden said successful appeal letter should contain the following:
- Summarize the denial, date of the letter and issues the RAC identified.
- Clearly state why you disagree with the RAC determination.
- Present as many arguments supporting your position as possible.
- Describe how the case meets the Medicare definition of an inpatient.
- Reference relevant sections of the medical record, citing the page number.
- Cite the hospital’s utilization management plan when it addresses relevant issues.
- Cite experience with commercial payers to show the community standard of care.
Read the HFM Revenue Cycle Strategist article on RACs (pdf).
