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.
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