RAC Forensics 101
PART 3: DENIALS MANAGEMENT
By Sharon Easterling, MHA, RHIA, CCS
THE DENIALS MANAGEMEN T process is the final step in the RAC process and can be the most time-consuming portion, depending on the circumstances of each case. Providers may appeal a RAC decision either through the discussion period or the formal Medicare Appeals Process. Becoming knowledgeable about all appeal levels helps providers meet deadlines, prepare supporting documentation, customize appeal letters, and enter new evidence in support of their cases. This article is the final installment in the series and reviews the denials management process for RACs. Part 1, published in the January issue, discussed requests and appeals. Part 2,
published in the February issue, examined the results letter
and discussion call.
The discussion period is the first avenue for providers to
overturn a denial well before refunding or recouping any
monies (see part 2 in this series). A provider who is clear,
factual, and has documented evidence supporting its original
claim can often use this period to its benefit. Providers should
use this period to have formal discussions with the RAC or
submit their case via fax.
Even with the best documentation, a provider cannot be
assured of overturning denials during the discussion period.
However, providers should put in the necessary effort to try
to overturn any denials before submitting to the Medicare
Medicare Appeals Process Deadlines
The Medicare Appeals Process is the next step in contesting
denials. It consists of five levels.
Level I: Redetermination through the fiscal intermediary
or Medical Administrative Contractor. Providers have 120
days from the date of receipt of the initial claim determination
to file a request for redetermination. They must file the request
by day 30 of the demand letter to avoid recoupment of the
denial amount on day 41.
Level II: Reconsideration through a qualified independent
contractor (QIC). Providers have 180 days from the date of
receipt of the redetermination decision to file a request for
reconsideration by a qualified independent contractor. They
must file the request by day 60 of receipt of the redetermination
to avoid recoupment. Level II is the last appeal stage in which
providers can submit additional information. The QIC should
return a decision to the provider within 60 days of receipt of
the reconsideration request.
Level III: Administrative law judge hearing. To present a
case to the administrative law judge, the amount in contoversy
(denial amount) must be at least $130,000. Providers have
60 days from receipt of the reconsideration decision to file a
request for a hearing. A decision will be provided within 90
days of receipt by the administrative law judge hearing office.
At this point, the Centers for Medicare and Medicaid Services
will recoup the overpayment plus interest.
Level IV: Medicare Appeals Council. Providers have 60 days
from the receipt of the administrative law judge decision to file
an appeal to the Medicare Appeals Council.