Medically unnecessary services and incorrectly coded items had the highest amounts of RAC overpayments collected in the demonstration project, according to CMS.
Recovery audit contractor (RAC) activity is picking up, but many healthcare providers are still waiting to see whether their preparations have paid off, according to a January survey of more than 400 healthcare providers conducted by MRB. Eighteen percent of survey respondents had received medical record requests (i.e., additional documentation requests) as of the time of the survey. Only 8% of providers received RAC denials.
As recovery audit contractors (RAC) begin to roll out complex reviews and request medical record documentation, compliant coding will continue to take center stage. And although correct coding is vital, sequencing codes is equally important because it affects MS-DRG assignment and payment.
Experts expect the RACs to begin auditing medical necessity this summer. Case managers may be asked to play a large role in appealing medical necessity denials because of their involvement in level-of-care determinations. To help case managers, we asked Medicare appeals experts to explain the case manager’s role in the appeals process.
