The Overall RAC Appeals Process
This session by Duane C. Abbey, Ph.D. is devoted to recent events surrounding the RACs and the backlog of appeals at the ALJ (Administrative Law Judge) and MAC (Medicare Appeals Council) level. There are currently about 500,000 pending appeals. In order to address the current appeals, it is estimated that 28 months will be required before new appeals can be considered. One of the main issues is that of medical necessity for inpatient admissions. The appeals process and the ever changing RAC audit issues will be addressed with this session.
Following questions will be answered in the session:
- What is the current status of the RAC program?
- Why are there so many appeals at the ALJ/MAC level?
- If there are delays in the appeals process, how will this affect our physicians and/or hospitals?
- What are the required timelines for the overall appeals process?
- How has OMHA (Office of Medicare Hearings and Appeals) reacted to appeals?
- Can the OMHA use statistical extrapolation to address the backlog?
- Why have the number of issues for physicians been increasing?
- Are the RAC issues for hospitals expanding?
- What are the potential issues for both physicians and hospitals?
- What are the key issues where the RACs are finding the greatest recoupment?
- How should physicians and hospital be working to have appropriate inpatient admissions?
- What is all the fuss about the ‘Over 2-Midnights’ rule?
- What happens when a hospital inpatient denial occurs? Does this affect physician coding and billing?
- What do physicians need to document in order to justify hospital services?
- To review current RAC activities
- To review the overall RAC appeals process
- To understand the role of the administrative law judges and the Medicare appeals council
- To discuss the enormous backlog of appeals at the ALJ/MAC level
- To assess the impact of the backlog both operationally and financially
- To review how OMHA (Office of Medicare Hearings and Appeals) is reacting to this situation
- To discuss one of the main issues causing the backlog – hospital inpatient admissions vs. observation services
- To discuss proper physician documentation for inpatient and observation services
- To review the ‘Over 2-Midnights’ Rule and the sub-regulatory guidance being issued
- To delineate current and anticipated physician issues
- To review current and anticipated hospital issues
- Objectives of the RAC program
- Objectives of other federal auditing programs
- Emphasis on hospital recoupment
- Growing number of issues for physicians/clinics
- RAC appeals process
- ALJs – Administrative Law Judges
- MAC – Medicare Appeals Council
- Specific timelines within the appeals process
- How is Recoupment handled?
- Current backlog of appeals at the ALJ/MAC Level
- Number of appeals
- Rate of appeals reaching the ALJ/MAC Level
- General categories of appeals
- OMHA’s reactions and operational plans
- Major concern for RAC denials of inpatient admissions
- What constitutes an inpatient admission?
- How inpatient is different from observation
- The ‘Over 2-Midnights’ Rule
- Subregulatory guidance
- Medical staff training and guidance
- RAC involvement
- Trends in RAC Audit Issues
- Crossover issues for hospitals and physicians
- Additional issues
- Pre-payment audits
- Issues involving statistical extrapolation
- New RAC contracts from CMS
- Sources for additional information
Get answers to your questions in a Q&A segment by the speaker after the session.
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