Jackson Davis HealthCare
Medicare Audit Defense
& Medicare Appeals
(303) 586-5003
support@jdhcare.com
Medicare RAC Appeals
Providers work hard and deserve payment for insuring exceptional care and services to Medicare beneficiaries. Yes, there are rules, but the system of rule-making and implementation is extraordinarily dynamic. The federal government has 10,000s of employees and contractors assisting in changing and enforcing the rules, it is simply impossible for a single provider to keep pace.
Over the past 25 years, Jackson Davis HealthCare professionals have assisted providers and attorneys nationwide in defending 1,000s of Medicare overpayment issues. As your unwavering advocate, Jackson Davis leads the nation in building winning Medicare appeals cases. Jackson Davis is the undisputed leader in understanding and synthesizing Medicare rules, regulations and guidance - no one understands Medicare coverage criteria better than we do - and we prove it everyday.
Do you realize that there are actually "consulting experts" that are on record saying that Medicare provides only guidance and it really doesn't have medical necessity or documentation rules that you must follow? Have you ever heard a snake oil salesman imply that medical necessity is in the eye of the beholder or that are ways to circumvent Medicare coverage criteria? Simply put, Jackson Davis is on your side and our honesty, knowledge, experience and passion makes us your best partner for developing winning Medicare appeals.
____________________________________________________________________________________________________________
Turning the Page - The Winning RAC Appeals Strategy
With the Medicare RAC audit program being in full force nationwide, providers are preparing for RAC audit denials and setting in motion a series of processes to successfully address RAC appeals. Hospitals, physicians, physical therapists, DME suppliers and a full range of other healthcare providers are quickly and aggressively turning their focus to fighting & winning RAC appeals. Defending Medicare or Medicaid auditor denials, avoiding potential CMS fraud allegations and holding on to hard earned cash reserves are all critical.
Based upon our work with providers facing CMS audits (PSC audits, ZPIC audits, RAC audits and MIC audits) and potential Medicare fraud implications, the 4 most frequently asked questions are (1) how do we keep our money, (2) how do we stop CMS audits and denials in the future, (2) how do we win current RAC appeals, and (3) how do we stop CMS audit outcomes from turning into Medicare fraud allegations.
Within the RAC Appeals section we address a wide range of issues and strategies to consider when initiating the Medicare appeals process. Most importantly, however, we simply can't emphasize enough the challenges to winning RAC appeals and the very real possibility of RAC audit outcomes becoming potential Medicare fraud issues. Here are a handful of things to consider when tackling RAC appeals:
1) CMS Payment Criteria will give you the winning hand
Several U.S. courts have held that a provider's adherence to CMS Payment Criteria trumps all in the evaluation of claim denials. In fact, the courts have held that - when CMS payment criteria exists for a given focus area - CMS MUST use the payment criteria when evaluating claims for payment.
2) Develop CMS Criteria-Based Case Summaries for all "winnable" RAC appeals
Nothing speaks louder in the Medicare or Medicaid appeals process than providers that painstakingly tie CMS Payment Criteria to medical records documentation and present an evidence-based argument for payment. On the other hand, using the "appeal everything" strategy and not making internal operational changes to adhere to CMS Payment Criteria is a guaranteed approach to facilitating potential Medicare or Medicaid fraud investigations.
3) Submit all required documentation during the first 2 stages of the RAC appeals process
It is critical that you file all the supporting documentation relating to a given case no later than Stage II - Reconsideration. After this stage, it is extremely difficult to add supporting documentation to a case under appeal. When completing RAC appeals and "mock audits" with providers across-the-country, we have found a number of hybrid medical record structures and significant challenges to submitting medical record documentation for review.
4) Focus on adhering to CMS Payment Criteria and winning your RAC appeals
Remember, the Medicare Appeals Council is the last administrative step in the Medicare appeals process. The Medicare Appeals Council relies heavily on CMS payment criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.
_____________________________________________________________________________________________________________
Medicare Audits / Medicare Appeals Resources
The RAC appeals can be challenging and may expose the provider to a wide range of Medicare fraud related issues. Please see the RAC Appeals section for further information and guidance relating to recommended appeals work plan components. The following are Medicare appeals documents highlighted on the cms.hhs.gov website:
RAC Appeals - The Medicare Appeals Brochure
RAC Appeals - Appeals Process Diagram
RAC Appeals - Limitation on Recoupment
Medicare Appeals - Denials & Overpayment Determination