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Using the Discussion Period2 years of experience
Jeannine Engel, MD FACPPhysician Advisor
University of Utah Health [email protected]
Patient in hospital Patient D/C
Patient chart
Attending verifies IP order
Resident writes IP order
CM/UR reviews chart for status
Facility coders
Facility billing
MAC pre‐payment probe
PAY‐MENT
RAC audit request
sends records
Appeal to QIC
Appeal to MAC
Appeal to ALJ
RAC Denial
MAC Denial
QIC denial
Payment refunded
OR
Months to 3 years
45 days
60 days
120 days
41 days
60 days
180 days
60 days
60 days
Theft facilitated by bounty hunters
ALJ audio confer‐ence
Paymentrecouped
From time of denial to recoupment if win at the ALJ : 2+ years
Patient in hospital Patient D/C
Attending verifies IP order
Resident writes IP order
CM/UR reviews chart for status
PAY‐MENT
RAC audit request
send records
Review remaining cases for discussion
Request re‐review
DISCUSSION occurs MD to
MD
RAC Denial
RAC response
RAC sets time for Discus‐sion
Payment refunded at 41 days from denial
Months to 3 years
45 days
60 days
14-28 days
immediately 2-4 weeks
1-3 week
Immediate to 2 weeks
Discussion results received
Time from denial to discussion results (and recoupment of payment): 8-12 weeks
Begin appeals on cases upheld in Discussion
Begin appeals on cases not included in Discussion
Paymentrecouped
Practical Tips
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Please review the attached additional materials and re-evaluate the original improper payment determination for:
RAC Audit Number: XXXXClaim Number: XXXXProvider Name: XXXXProvider Number: XXXX
Dear RAC,The Provider respectfully disagrees with the original determination by RAC, stating that the care provided to the above mentioned patient could have been provided in a less intense setting than the inpatient setting. As such, we officially request that a follow up review of the claim be performed on the documentation that was originally sent for review.
Please feel free to contact me at the below written telephone number.
Thank you,
Practical Tips
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• MD documentation: clinic not
es prior; Outside records• Nursing notes; vital signs; anesthesia pre‐op• Case Management
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• “what happened to the patient next?”–
• Surgical cases for instance
Practical Tips
•––––
• “can I tell you anything else about this patient?”• “what is your opinion about this case?”
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• RAC employee? Consultant? Location? Specialty? Age?
Practical Tips
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–• Be willing to give yourself a learning curve for success!!• Negative results are still results
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University of Utah data
University of Utah data
University of Utah data
University of Utah data
University of Utah data
University of Utah data
Summary
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Lisa Whittaker, RN, BSN
Sara Feltz, PA Katie Brown
Holly Stevens
Brian Watts, JDDiana SnowKaren WilsonRussell Vinik, MD
Acknowledgements:
