To help you make a decision about whether to rebut a RAC finding and begin a discussion with the RAC that issued it, we've listed 10 steps to use in the process.
1. REVIEW the RAC rationale behind the determination that a claim has been overpaid. Then review the documentation in the medical record associated with the claim. Finally, review the applicable guidelines for the dates of service of the treatment represented by the claim (check CMS manuals, Coding Clinic, CPT Assistant, etc.).
2. FIND the "meat and potatoes" of an argument that supports your position that the RAC finding is incorrect and should be reversed. As an aside, you also should review any determinations of underpayments to determine the basis for the RAC's decision. There may be opportunities to revise processes and/or perform education related to the issues.
3. DECIDE whether to submit a response to the RAC. There is a form that CMS has developed for such responses ("Request to Open a Discussion Period"). When responding to automated review findings, use one form per issue. When responding to complex review findings, use one form for each claim under dispute.
4. CHECK with your RAC on deadlines for submitting a response. It likely will be about 15 days (and remember, a response or request for discussion with the RAC does not impact any actions regarding filing an appeal or the timelines set for the appeal process.)
5. IDENTIFY all information related to the claims and individuals that are the subject of the response. Also, clearly identify a contact person for your facility who should receive any response from the RAC.
6. PARAPHRASE the reason for the RAC's decision and focus closely on the issue that you are rebutting.
7. DISAGREE respectfully with the RAC's decision. Provide your rationale succinctly and firmly. For example, "we respectfully disagree with the suggested changes. The following clinical and coding documentation supports the code assignment of 415.19 - pulmonary embolism - as the principal diagnosis and also supports the original DRG assignment of 175."
8. CITE official sources to support your position like CMS regulations, articles from Coding Clinic or CPT Assistant, textbooks, etc.
9. POINT OUT specific documentation to support codes or medical necessity. One tip is to use an arrow sticker to highlight specific wording on a page that supports your position.
10. SUMMARIZE your rationale. For example: "in summary, based on the documentation that exists throughout the medical record (e.g. the circumstances of admission, clinical presentation and treatment provided), we strongly feel that the diagnosis of pulmonary embolism is the principal diagnosis. This position is supported by the discussion published in the above listed issue of Coding Clinic."
While not all RAC determinations should be rebutted, there are many that should be. These 10 steps will guide you in writing a convincing request to open discussions with the RAC.
About the Authors
Cheryl E. Servais, MPH, RHIA, has more than 25 years of experience in health information management. In her position at Precyse Solutions, Ms. Servais' responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the executive and board levels and takes an active role in professional organizations.
Margi Brown, RHIA, CCS, CCS -P, CPC, CCDS, is Director of RAC Services for Precyse Solutions, LLC. She has over 30 years experience in the HIM arena and works with the C.A.R.E (CDI, Audit, RAC Services and Education) team at Precyse.
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