RAC Audits, doctor with paperwork

RAC Audits and Medicare Claim Denial

Help is on the way, but more immediate fixes are available

If you are a hospital administrator, you know the havoc that can be caused by RAC Audits and the uncertainty of Medicare payments. The frustration of denied claims, because you can be faced with a 4+ year appeals process due to the backlog of cases with HHS. This, of course, makes financial planning very difficult since you are dealing with a very uncertain revenue stream.

Recently, a federal judge requested that the American Hospital Association (AHA) weigh in with ideas on how HHS can fix their system, including the length of backlogs. This is a welcomed direction for many administrators but will take time for proposed resolutions and implementation.

What can you do now to improve the outcome of your RAC Audits?

The RAC audits can consistently reduce and or deny payment for hospital admissions based on the patient status. Patient status becomes particularly complicated when a patient arrives via the emergency room.

Active monitoring and participation by Case Management can prevent payment reduction and denials based on inaccurate patient status. The correct patient status will also drive the level of care and patient satisfaction.

Let’s see how active case Management in the ED can improve you bottom line.

Benefits of Case Management collaboration in the ED department

Case managers and improved process implementation can reduce Medicare claim denials through added oversight and efficiency, saving hospitals money but also avoiding a lengthy and costly appeals process.

Consider these benefits of having case managers in you ED, they:

  • Provide much-needed oversight in directing patients to appropriate care, thereby reducing the number of unnecessary admissions but also guiding patients to their appropriate path for care
  • Educate and provide Advanced Beneficiary Notices (ABNs) in the ED to patients being admitted, so they are aware prior to service
  • Provide patient education and help reduce the number of re-admissions
  • Aid in the outpatient process by delivering Medicare Outpatient Observation Notice (MOON) letters when appropriate

Change can be good but also confusing for your ED team to implement. To ease into this type of approach, make sure to educate the ED staff as to the specific role of the case manager. Explain the benefits and opportunities to improve revenue and patient care. Effective collaboration and healthy rapport between various roles within the ED are the key to the reduction of payment denials. 

If you are looking for these types of improvements for your facility, a case manager will make an impact on your bottom line.

However, keep in mind that without the proper automation and processes in place, your team’s success may be elusive. Make sure to invest not only in the right people but also the systems and tools to guarantee your team success! 

Related: Audit and Reconciliation

Sunlit Cove Healthcare Consultants

We provide management and consulting services to help healthcare businesses run efficiently. Navigating the dynamic and complex revenue cycle management is a challenge for many health plans, health care vendors, and providers. Our consulting services are available to assist with your day-to-day operations and provide expertise in growth and change management. We manage all aspects of your enterprise from the development of the revenue cycle management process to the completion of your business cycle.