Appeals Process / Expert Witness
ACS has worked with hospitals on DRG and medical necessity denials since the company’s beginnings over 30 years ago. Even though RAC denials have now garnered the majority of recent attention, historically fiscal intermediaries, MACs, QIOs, etc. have also issued DRG changes and medical necessity denials. ACS has continually assisted hospitals with successful appeals and has also served as expert witness for the OIG.
Whether it is an appeal of an adverse decision by the MAC, CERT, RAC, SMRC, ZPIC/UPIC, ACS has successfully worked with clients to get inappropriate decisions overturned.
Specifically during the RAC demonstration project, we assisted client hospitals in the demonstration states (CA, FL, NY) with appeals at various levels including presentations to the administrative law judge (ALJ). We have found that hospitals rarely needed to pursue the appeal to the Appeals Council or US District Court because of their success at earlier levels of appeal.
ACS is available to assist with review of records prior to submission to the RAC (or other external review agency) as well as medical record review and writing of appeal letters when indicated. We welcome the opportunity to assist client hospitals with this important process.