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Regulatory Audits Desk Reference



Regulatory Audits Desk Reference

Regulatory Audits Desk Reference


Regulatory auditors (RACs, MACs, MICs) are auditing hospitals nationwide looking for overpayments that may have occurred over the last few years. Hospitals need a strategy and a process for addressing these audits and repayment demands. About 67 percent of RAC appeals are successful, but only 12 percent are appealed.

Successfully respond to regulatory auditor’s claim reviews with this new reference from Optum.

You’ll get expert coding and documentation guidance and understand the documentation requirements for targeted inpatient medical necessity reviews. Ensure successful appeals for overpayment determinations with the following:




Understand audit threats. Complete listing and description of all the regulatory agencies and their auditing functions.

Appeal letter templates.  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 listed, along with the related coding and medical necessity guidance for each.

List of commonly associated laboratory and diagnostic tests under MCC and CC diagnoses.

Find out what documentation is needed for each targeted DRG and inpatient medical necessity reviews.

Locate diagnoses that require additional physician specificity in documentation under convenient specificity tables.  in order to assign a code that is designated an MCC or CC such as CHF, COPD, arthropathies, and ESRD.