Appeal Services – RAC and other audits
The Craneware Group Consulting offers comprehensive Recovery Audit Contractor (RAC) audit services. We are prepared to manage some or all of the tasks related to Medicare RAC audits. We can appeal any type of denial through the first three levels of appeal and coordinate with legal counsel for the final two levels of appeal. The Craneware Group has been helping hospital effectively appeal Recovery Auditor overpayment determinations since the early days of the demonstration phase, and our clients have significantly higher appeal success rates than the national average as reported by CMS.
The Craneware Group applies proven appeal strategies to your RAC denials, ensuring that revenue inappropriately targeted for recoupment by the RAC auditors is appealed and successfully overturned.
Medical Necessity Appeals
The Craneware Group Consulting has developed effective appeal arguments and strategies based on our experience of what worked at the ALJ level of appeal and above. The use of Hospital/UR Admission guidelines, physician orders for inpatient care, community standards of care, and the complexity of patient and/or procedure must be taken into account at the beginning of the appeal process to ensure success at the ALJ level.
For coding appeals, The Craneware Group Consulting verifies the validity of the denial and takes the follow up actions necessary to resolve the coding issue. These denials usually fall into three categories – coding errors, when the coded diagnosis/procedure was not documented by the physician in record, or simply missing documentation.
Fully assess your organization’s process for assuring claims are paid correctly and fully. This includes a review of the identification, feedback and resolution of under and over payment variances, either with or without the use of a contract management system. Procedures will be developed to assure all revenue associated with underpayments is collected in full. Revenue identified as “lost” will be recovered within payor allowable time limits.
The Craneware Group employs certified case managers, certified inpatient and outpatient coders, experienced patient financial service and HIM management staff for billing error denials, on-call physician advisors, and affiliated legal counsel.