+ Site Statistics
+ Search Articles
+ PDF Full Text Service
How our service works
Request PDF Full Text
+ Follow Us
Follow on Facebook
Follow on Twitter
Follow on LinkedIn
+ Subscribe to Site Feeds
Most Shared
PDF Full Text
+ Translate
+ Recently Requested

Recovery Audit Contractor audits and appeals at three academic medical centers

Recovery Audit Contractor audits and appeals at three academic medical centers

Journal of Hospital Medicine 10(4): 212-219

Outpatient (observation) and inpatient status determinations for hospitalized Medicare beneficiaries have generated increasing concern for hospitals and patients. Recovery Audit Contractor (RAC) activity alleging improper status, however, has received little attention, and there are conflicting federal and hospital reports of RAC activity and hospital appeals success. To detail complex Medicare Part A RAC activity. Retrospective descriptive study of complex Medicare Part A audits at 3 academic hospitals from 2010 to 2013. Complex Part A audits, outcome of audits, and hospital workforce required to manage this process. Of 101,862 inpatient Medicare encounters, RACs audited 8110 (8.0%) encounters, alleged overpayment in 31.3% (2536/8110), and hospitals disputed 91.0% (2309/2536). There was a nearly 3-fold increase in RAC overpayment determinations in 2 years, although the hospitals contested and won a larger percent of cases each year. One-third (645/1935, 33.3%) of settled claims were decided in the discussion period, which are favorable decisions for the hospitals not reported in federal appeals data. Almost half (951/1935, 49.1%) of settled contested cases were withdrawn by the hospitals and rebilled under Medicare Part B to avoid the lengthy (mean 555 [SD 255] days) appeals process. These original inpatient claims are considered improper payments recovered by the RAC. The hospitals also lost appeals (0.9%) by missing a filing deadline, yet there was no reciprocal case concession when the appeals process missed a deadline. No overpayment determinations contested the need for care delivered, rather that care should have been delivered under outpatient, not inpatient, status. The institutions employed an average 5.1 full-time staff in the audits process. These findings suggest a need for RAC reform, including improved transparency in data reporting.

Please choose payment method:

(PDF emailed within 0-6 h: $19.90)

Accession: 058710970

Download citation: RISBibTeXText

PMID: 25707363

DOI: 10.1002/jhm.2332

Related references

Recovery Audit Contractor medical necessity readiness: one health system's journey. Professional Case Management 16(5): 232-7; Quiz 238-9, 2012

Recovery audit contractors and Medicare audits: successful strategies for defending audits. Caring 27(11): 30-36, 2008

Hospitalizations With Observation Services and the Medicare Part A Complex Appeals Process at Three Academic Medical Centers. Journal of Hospital Medicine 12(4): 251-255, 2017

Preparing Academic Medical Centers for the Clinical Learning Environment Review: Alliance of Independent Academic Medical Centers National Initiative IV Outcomes and Evaluation. Ochsner Journal 16(2): 166-171, 2016

CMS's Recovery Audit Contractor Initiative. Journal of Oncology Practice 3(5): 255-255, 2018

What every CEO should know about Medicare's recovery audit contractor program. Journal of Healthcare Management / American College of Healthcare Executives 56(3): 157-161, 2011

The recovery audit contractor program: an overview. Health Care Law Monthly 2009(6): 2, 2009

RAC ready. How to prepare for the Recovery Audit Contractor program. Journal of Ahima 80(2): 28-31; Quiz 33-4, 2009

"RAC and roll": preparing your practice for the recovery audit contractor program. Journal of the Kentucky Medical Association 107(4): 135-139, 2009

Recovery audit contractor reviews: knowing what you are up against is half the battle. Annals of Health Law 19(1 Spec No): 253-257, 2010

Responding to the recovery audit contractor program: a system-wide approach. Physician Executive 37(3): 44-49, 2011

Recovery audit contractors: Mississippi physicians and Medicare audits. Journal of the Mississippi State Medical Association 50(8): 292-293, 2009

Medicare's recovery audit contractor program: inpatient rehabilitation facilities are taking back takebacks, but enough?. American Journal of Physical Medicine and Rehabilitation 90(5): 426-431, 2011

A comparison of baseline characteristics of study participants from urban academic medical centers and rural community-based medical centers. Journal of Investigative Medicine 45(1): 158A, 1997

Ensuring that patients meet admission criteria. One-day stays focus in RAC (Recovery Audit Contractor) demonstration project. Hospital Case Management 16(11): 164-165, 2008