Question

As the HIM Manager of JCCC Hospital, you received RAC audit findings from your hospital's RAC Coordinator. The RAC Coordinator has asked you to review the findings and the health record documentation, then suggest whether or not the hospital should appeal the RAC audit findings. The audit findings state that $323.050 needs to be repaid to Medicare due to billed services not rendered. Your review of the health record documentation compared to the audit findings reveals that $43,607 of billed services were not properly documented in the health record. Do you think the hospital should appeal the RAC findings? Why or why not?

Answer 1

Hospitals should begin to prepare for RAC reviews by assembling an internal team to plan and implement process improvements to reduce RAC vulnerabilities. A self-audit to identify risks is an important first step. Once RAC audits begin, hospitals should internally track any and all RAC activity to minimize your financial risk and ensure that it responds to the RACs in a timely fashion to avoid technical denials. An internal tracking system will help monitor the status of claims in order to preserve appeal rights on every claim that is identified as an overpayment.

Do you think the hospital should appeal the RAC findings? Why or why not?

Yes, they should appeal after they have properly fixed the $43,607.00 billing issue.