title: Recovery Audit Contractor medical necessity readiness: one health system's journey.
abstract: OBJECTIVE
  To develop a sustainable approach to Recovery Audit Contractor medical necessity readiness that mitigates the regulatory and financial risks of the organization.
  
  
  METHODS
  Acute care hospitals.
  
  
  CONCLUSIONS
  Utilizing the model for improvement and plan-do-study-act methodology, this health system designed and implemented a medical necessity case management program. We focused on 3 areas for improvement: medical necessity review accuracy, review timeliness, and physician adviser participation for secondary reviews. Over several months, we improved accuracy and timeliness of our medical necessity reviews while also generating additional inpatient revenue for the health system. We successfully enhanced regulatory compliance and reduced our financial risks associated with Recovery Audit Contractor medical necessity audits.
  
  
  CONCLUSIONS
  A successful medical necessity case management program can not only enhance regulatory compliance and reduce the amount of payments recouped by Medicare, but also generate additional inpatient revenue for your organization. With health care reform and accountable care organizations on the horizon, hospitals must find ways to protect and enhance revenue in order to carry out their missions. This is one way for case managers to help in that cause, to advocate for the care of their patients, and to bring value to the organization.
authors.affiliation: IU Health North Hospital, Carmel, IN 46032, USA. j1scott@iuhealth.org
authors.forename: Judith A
authors.initials: JA
authors.lastname: Scott
authors.forename: Mindy
authors.initials: M
authors.lastname: Camden
mesh_terms: D019090:Case Management / Q000191:economics / Q000592:standards*; D018672:Community Health Planning / Q000191:economics / Q000592:standards*; D003695:Delivery of Health Care / Q000191:economics / Q000592:standards*; D006801:Humans; D007449:Investments; D008485:Medical Audit / Q000191:economics / Q000379:methods / Q000592:standards*; D006278:Medicare / Q000191:economics / Q000592:standards; D017146:Models, Organizational; D058996:Quality Improvement; D018570:Risk Assessment; D014481:United States