Jennifer Colagiovanni, an attorney at Wachler & Associates in Royal Oak, Mich., makes the following four points for hospitals appealing decisions by recovery audit contractors.
Appeal short-stay admissions. If an admission should have been billed as a short stay, RACs will simply deny payment rather than downgrade the claim to a short stay. "In many cases, if the claim is denied, you are almost out of luck," Ms. Colagiovanni says. Her firm has had some success, however, at the third level of appeal, when the case reaches an administrative law judge. Some ALJs have allowed the claim to be downgraded so that the hospital can be paid at the short-stay level.
Work with RACs in discussion periods. When RACs deny a claim, hospitals have a limited period of time to appeal directly to the RAC in what is called the discussion period. RACs tend to stand by their decisions in these exchanges, but in a few cases Wachler has convinced the RAC to reverse its decision. Even here, though, the RAC was slow to respond and the hospital had to continue to go to the next level of appeal, which must be filed within 30 days of the denial.
Approved issues can be confusing. RACs must post CMS-approved issues on their websites before pursuing them. But it can be difficult to keep track of approved issues because some RACs do not post them in chronological order. Also, when a RAC updates an issue, it may simply rewrite the text without noting the text has been changed. To deal with this, the RAC compliance team should be noting changes in RAC postings each day. "If you keep track of postings, you'll realize it when they make changes," Ms. Colagiovanni says.
Volume of appeals will pick up. As the RACs move to more advanced cases, the volume of appeals is expected to increase. The permanent RAC program started in 2008, but only involved provider education. RACs started automated reviews in 2009, but these cases generally involved obvious billing errors that couldn't be defended in an appeal. Complex review cases, which lend themselves to appeals, did not start until 2010, and RACs have been expanding approved issues since then.
Learn more about Wachler & Associates.
Appeal short-stay admissions. If an admission should have been billed as a short stay, RACs will simply deny payment rather than downgrade the claim to a short stay. "In many cases, if the claim is denied, you are almost out of luck," Ms. Colagiovanni says. Her firm has had some success, however, at the third level of appeal, when the case reaches an administrative law judge. Some ALJs have allowed the claim to be downgraded so that the hospital can be paid at the short-stay level.
Work with RACs in discussion periods. When RACs deny a claim, hospitals have a limited period of time to appeal directly to the RAC in what is called the discussion period. RACs tend to stand by their decisions in these exchanges, but in a few cases Wachler has convinced the RAC to reverse its decision. Even here, though, the RAC was slow to respond and the hospital had to continue to go to the next level of appeal, which must be filed within 30 days of the denial.
Approved issues can be confusing. RACs must post CMS-approved issues on their websites before pursuing them. But it can be difficult to keep track of approved issues because some RACs do not post them in chronological order. Also, when a RAC updates an issue, it may simply rewrite the text without noting the text has been changed. To deal with this, the RAC compliance team should be noting changes in RAC postings each day. "If you keep track of postings, you'll realize it when they make changes," Ms. Colagiovanni says.
Volume of appeals will pick up. As the RACs move to more advanced cases, the volume of appeals is expected to increase. The permanent RAC program started in 2008, but only involved provider education. RACs started automated reviews in 2009, but these cases generally involved obvious billing errors that couldn't be defended in an appeal. Complex review cases, which lend themselves to appeals, did not start until 2010, and RACs have been expanding approved issues since then.
Learn more about Wachler & Associates.