RACs identified more than $1.03 billion in improper Medicare payments as of March 27, 2008, with 96% being overpayments which were collected from providers. With the RAC program expanding nationwide, hospitals need to be prepared to appeal those denials that are worthy of appeal. In this session, EHRs RAC appeals experts will outline a hospital's rights of claims appeal, and help gain an understanding of RAC appeal best practices that are important to every facility.

The need for this session was evaluated based on evaluation results from past EHR Accelerated Compliance Training (ACT) Series audio conference and various speaking engagements, specifically those related to the RACs and RAC processes. Program participants identified through follow-up survey feedback their desire to learn more about their rights, appeals processes and the best practices they should implement at their facilities.

This session will incorporate a team-teaching format and will incorporate case studies to reinforce learning through best practices and peer-to-peer sharing. The cases will also be takeaways so the participants can share them and educate other members of their staff through inservice training sessions or other educational programs.

An outline for the session is provided below:

I. Overview of the current regulatory environment
II. The importance of medical necessity reviews and getting it right the first time
III. Understanding the QIC and reconsideration appeals
IV. Overview of the Administrative Law Judge and its appeals process
a. Qualifications of an ALJ
i. Licensure requirements
ii. Experience requirements
iii. Examination process
b. Duties of an ALJ
c. The ALJ process
i. Preparation of the memorandum
ii. Medical necessity
iii. Material evidence
V. Discussion of the Departmental Appeals Board level of appeals
VI. Understanding recoupment and interest
VII. EHR Case Study on a criteria variant inpatient admission for chest pain
VIII. RAC Appeal Dos & Donts
IX. Q&A with presenters