In an effort to collect on perceived overpayments to providers, Medicare is adopting evidence-based coverage policies, defining clinical payment criteria, forcing the issue of evidence-based outcomes, verifying supporting medical documentation and insuring claim payment levels. This is being done in an effort lighten the load of a strained national budget. Independent medical collection agencies (Recovery Audit Contractors – RACs) will initially audit and reach deep into the pockets of hospitals, inpatient rehabilitation facilities and physician practices.

The All Star approach to the Medicare RAC solution is designed to manage the providers appeal process to the RAC audit and denial of medical claims.  This will include the use of multiple dashboards (Administration, Financial, Risk Analysis, Process Improvement) and tools (CRM, Claim History, Task Management) to monitor and perform work.

Implementing the All Star Medicare RAC solution will provide:

• Claim level management – Track primary responsible employee, track appeal process timelines, manage tasks and expected completion dates, CRM to track communications with RAC personnel, track shipping information, track medical records request costs, track interest due on recovered funds.

• Administration management – Graphical View of all claims under audit, identify amounts under audit at each appeal level, identify claim aging and appeal date risks, drill down into claims

• Risk management – Graphical View of all claims under audit by DRG/PDx, identify amounts under audit for each type of claim, view graphs of other claims with matching demographics, quantify additional audit risk, identify other claims won or lost with the same demographics, quantify audit patterns, identify denied claims trends and the potential for claims to be red flagged.

• Financial management – Graphical View of all claims under appeal, track amounts recovered by RAC and amounts that are about to be recovered (withheld),identify amounts under appeal, identify amounts lost YTD and QTD, identify amounts won on appeal YTD and QTD.

• Process management – Graphical View of all claims audited by denial reason, explore specific DRG/PDx claims with coding errors, identify procedural deficiencies patterns.