How to Pick a Winning RAC Appeal Strategy

In this episode, we cover how to profile your Administrative Law Judges, how to use private payor coverage to your advantage, how to decide whether or not to bring attorneys to ALJ appeal court dates, and how appeal letter templates can help turn one successful RAC appeal into many.

Transcript of the Podcast:
Hello and welcome back to the ClaimTrust RAC Insight podcast, brought to you by ClaimTrust, the leader in software tools and consulting services that help hospitals get paid for all of the work they do.

This podcast is part two of our three part series on “Top Tips for RAC Success”.  It covers our top, highly valuable but sometimes overlooked tips for helping your organization successfully take on the RAC challenge with the most efficient use of your resources. 

The RAC Insight Top Tips were created by Karen Bowden, President of Consulting for ClaimTrust and a thirty year veteran in the areas of hospital administration and revenue cycle.  Her team led one of the nation’s most successful RAC appeal efforts during the RAC demo phase, recouping more than $6.8 million for ClaimTrust clients and achieving a 84% success rate on RAC appeals.Our previous podcast covered tips 1 through 3, so we will begin this podcast with Tip number 4.

Profiling the Administrative Law Judges or ALJs

Another highly-successful technique we use to improve our success rates on RAC appeals is profiling the ALJs.  Once you appeal to the ALJ-level, you are in front of a judge who gets to make his or her own decisions about what criteria to apply and how to weight the competing arguments.

To succeed you need to get inside the head of the ALJ as much as you can, and try to understand the issues that they find most compelling and relevant.  We had one ALJ who thought that the pre-anesthesia risk score which assigns a level of acuity to the patient, was proof positive for inpatient level of care.  So for that judge we always made sure we checked that document.

Each judge will be different, but the kinds of things you can look at to start building your ALJ profiles include looking at the letters issued in judgments and reviewing questions asked by the judge during RAC proceedings.  These are not currently part of the public record due to privacy concerns, but you may find other organizations in your region willing to pool insights and experience with you.

Community Standards.

We worked a lot of RAC appeals during the demo phase and learned a great deal about the most useful areas of the law and the CMS regulations to rely on for appeals.  One area of the law that proved extremely useful was the Social Security Act, and in particular its Limitation of Liability provision, which says in part that:

Quote……..no provider shall be civilly liable for action taken in compliance with professionally developed norms of care and treatment operating in the area where such doctor took such action….end quote.

Looking at what the private payors cover in your region is a great first step.  You can also look at local medical society publications for any published guidelines.

Don’t bring attorneys or physicians to ALJ appeal.

When our team first started taking appeals to the ALJ, we were notified that a CMS attorney would be present and so we made sure we brought our own along.  ALJ appeals are not like court cases where only the attorneys know how to follow the prescribed rules and procedures.  After we saw that all of the back and forth was between the judge and our case manager experts and that neither attorney contributed to the discussion at all, we decided that we could trim an easy $300 an hour from our budget.

Learning from Success – Templating

Once you get a few RAC response and appeal processes under your belt, you will have generated a set of letters and strategies that have either worked or not worked for your appellate bodies, your areas of care, your RACs, etc.  This is extremely valuable information that should be kept, organized and reused in a systematic way to ensure you are continuing to do what works and avoid what doesn’t.

One of the most valuable best practices I can share is to convert your appeal letters into templates that can be repurposed for similar appeals.  Build a database of these templates and reuse them as much as you can.  Your process will not only be faster and easier, but also more successful.  We have a continually growing list of letter templates, forms and winning appeal strategies in our RAC tool that cover a wide range of appeal levels and claim types, and they are one of the biggest reasons organizations chose our tool for their RAC workflow.