Home » Regulatory Audits Desk Reference: A Guide to Successful Appeals of RAC, MAC, and Other Payment Recovery Efforts by Optum
Regulatory Audits Desk Reference: A Guide to Successful Appeals of RAC, MAC, and Other Payment Recovery Efforts Optum

Regulatory Audits Desk Reference: A Guide to Successful Appeals of RAC, MAC, and Other Payment Recovery Efforts

Optum

Published October 1st 2013
ISBN : 9781601519573
Paperback
415 pages
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 About the Book 

Regulatory auditors (RACs, MACs, MICs) are pursuing hospitals nationwide for overpayments that may have occurred in the prior three years. Hospitals need a strategy and a process for addressing these audits and repayment demands. Approximately 67MoreRegulatory auditors (RACs, MACs, MICs) are pursuing hospitals nationwide for overpayments that may have occurred in the prior three years. Hospitals need a strategy and a process for addressing these audits and repayment demands. Approximately 67 percent of RAC appeals are successful, but only 12 percent of repayment demands are appealed. Successfully respond to regulatory auditors automated and complex claim reviews with this new reference from Optum. Youll get expert coding and documentation guidance and learn documentation requirements for targeted inpatient medical necessity reviews. Ensure successful appeals for overpayment determinations with these features: Features and benefits Understand audit threats. Complete listing and description of all the regulatory agencies and their auditing functions. Appeal letter templates. Includes customizable response letters for overpayment demands with recommended language. MediCAID RACs - new set of DRGs and medical necessity for review. Primary DRGs reviewed by the RACs are listed, along with the related coding and medical necessity guidance for each. List of laboratory and diagnostic tests commonly associated with MCC and CC diagnoses. Documentation requirements. Find out what documentation is needed for each targeted DRG and for targeted inpatient medical necessity reviews. Documentation specificity tables. Locate diagnoses that require additional physician specificity in documentation in order to assign a code that is designated an MCC or CC such as CHF, COPD, arthropathies, and ESRD. Best practices. Get expert insight on responding to automated reviews.