Updated on: June 22, 2012

Preparing to be a Successful Appellant: First Steps

By
Original story posted on: October 15, 2009

p-clarkNurse Auditor

ED NOTE: Meet Patty Clark, RN, BSN, who became the Nurse Auditor responsible for appealing medical necessity denials in 2007 when the RAC demonstration program was at its height.

She has appealed successfully at the fiscal intermediary, the qualified independent contractor and the Administrative Law Judge levels on behalf of the Wuesthoff Health System, comprising the 115-bed Wuesthoff Medical Center-Melbourne, and the 291-bed Wuesthoff Medical Center-Rockledge, both of which serve the healthcare needs of Brevard County residents.


This is her story.


Wuesthoff Health System was part of the RAC demonstration program conducted by CMS from 2005-2008.  Our experience with the RAC was similar to the other hospitals in the targeted states. Initially, requests for medical records were minimal, but by the end of the demonstration program, 3,000 medical records had been requested and provided to the RAC.


The majority of the requests occurred in the second half of 2007.  Of the 3,000 records requested, approximately 1,200 were identified by the RAC as having overpayments related to medical necessity.


The demonstration program was overwhelming due to the amount of requests and the amount of time spent in tracking the process, appealing and doing follow-up to ensure appeals were received and the repayments were made.


We are fortunate to have a leg up when it comes to the permanent program. We have put a formal system in place to track the permanent RAC process, our inter-departmental communication has been improved and documentation has been strengthened.


We learned many valuable lessons from the demonstration program that will help us be more prepared now that the permanent program is upon us.


And this is what I share with you.


You're Prepared, Right?


You've done audits of the issues the RACs targeted during the demonstration program, haven't you? You've educated key staff. You've implemented a tracking system (if not, get on that! There may not be time once you start getting requests.)


Speaking of requests...where are they? Talk about a slow process...not knowing when the first wave will hit, how many requests there will be, what issues will be reviewed, etc. can be daunting.


Personally, I think it's a ploy to catch us all unaware. Don't be lulled into complacency.  Keep preparing and educating.


Speaking of preparing ... many times the RAC target was one- to two-day length of stays: "low-hanging fruit," I believe it's called.


Anyone who has reviewed the documentation of such admissions can guess why - there is usually little in the way of documentation to prove that the patient required an inpatient level of care. But if the physician ordered inpatient care, the patient must have required it, right? I believe so. And, according to the Medicare Benefit Policy Manual, Pub 100-2 Chapter 1, Section 10, CMS does too:


"...the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs...."


To Admit or Not to Admit


Factors to be considered when making the decision to admit include:

 

  • The severity of the signs and symptoms exhibited by the patient.

  • The medical predictability of something adversely affecting the patient.

  • The need for appropriate outpatient diagnostic studies to assist in assessing whether the patient should be admitted; and

  • The availability of diagnostic procedures at the time and location in which the patient presents.


So, to prepare an effective appeal, try this approach:


If the reason for inpatient admission is not clear in the physician documentation, follow the directive above. Look at the severity of the patient's illness and his or her current medical needs. What were the signs and symptoms that proved they required an inpatient level of care?


Next, examine the patient's particular needs that led his or her physician to make the determination that they required care in an inpatient setting. What were the co-morbidities that impacted evaluation and treatment?


Finally, consider the potential risk to the patient if he or she does not receive inpatient level of care.


Take what you have discovered about the patient's current and past medical needs, combine it with the risk faced and paint a picture of why the patient required inpatient service.


You can't read the physician's mind, but you can use your medical knowledge and experience to help the RAC reviewer see that inpatient care was "medically reasonable and necessary."


About the Author:


Patty Clark, RN, BSN, is the Nurse Auditor for Wuesthoff Health System. She has served as a member of her organizations RAC task force for the past two years. She attended Florida State University and is a graduate of the University of Central Florida College of Nursing.


Contact the Author:


patricia.clark@wuesthoff.org

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