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We have had a total of 92 complex review cases requested, all for DRG validation.


Our RAC is CGI, and it does not have any medical necessity issues approved or posted on its website yet. The first round of requests was for 10 records from each of our facilities. Out of the 20 records, we had three denied.  We agreed with the DRG change in one case, and we appealed the other two. In addition to appealing, we scheduled a discussion with the RAC.


A conference call was held with the supervisors of medical records, our RAC coordinator and the RAC. During this discussion we were able to demonstrate where the RAC had overlooked the documentation in the record that allowed us to come up with the DRG that we did. We were advised verbally that there ultimately would be no denial on either of these cases. We consider the cases pending since we have not received confirmation from the RAC that the denials are reversed; we have submitted a formal appeal in addition to holding the discussion period.


Our second request was for 72 records, or 36 from each facility. To date we have not heard from the RAC on 42 of these cases, but we have received denial determinations on three of them. We have had a discussion with the RAC on one of the three denials and have determined that the RAC’s DRG reassignment was correct.  The other two denials are pending our own internal reviews.


It is rather apparent that our RAC is moving slowly. We are eligible to have up to 500 records requested at a time for both of our facilities and so far only have had a total of 92. Of course, this is not a complaint by any means, just an observation. I also would suggest that everyone take advantage of the discussion period, but do continue to proceed with your appeals to avoiding missing the deadline.


I have been at TriHealth for 33 years in various capacities. My more than 10 years in utilization review gives me the knowledge and experience needed to support these areas. I have developed and implemented the care coordination department, transitioning it from a utilization review department to a comprehensive care management department.  I implemented eligibility software in the registration areas and I also helped develop and implement a software product that facilitates accuracy of insurance selection in registration. I also provide the organization with information on network rules for managed care plans. Compliance with Medicare conditions of participation is one of my responsibilities specific to care management.


I developed and implemented the appeals management department, which consists of nurses appealing medical necessity and network rule denials from commercial payers. I also implemented a medical necessity software program for Medicare LCDs and NCDs that screens for medical necessity at the point of scheduling. I have assisted in implementing an outpatient benefit verification/precertification department. I am a member of the American Association of Managed Care Nurses and actively participate in HFMA and the National Association of HealthCare Access Managers.


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