Put lessons learned from the RAC demo to work
Put lessons learned from the RAC demo to work
Track your data in detail and appeal aggressively
Before the Recovery Audit Contractor (RAC) issued its first requests for data, Sharp HealthCare in San Diego assembled a committee of stakeholders to determine what the process would probably be like, how to track requests, how to ensure that the health system responded in a timely manner, and what the appeals process should be.
The team included representatives from patient access, financial services, corporate compliance, care management, and the CFOs of the four acute care hospitals in the Sharp system, according to Tony Guerra, CFO for Sharp Coronado, a 204-bed hospital in San Diego.
A multidisciplinary RAC steering committee is essential to creating a smooth and timely response when the RAC requests come in, adds Lori Dempsey, vice president of financial compliance at Lutheran Medical Center in New York City, who spearheaded the RAC efforts at another large New York hospital.
Dempsey, who has a background in patient accounting, also worked with the Hospital Association of New York, a health care trade advocacy group, to provide input from the provider perspective on the organization's electronic database that hospitals could use to log in the cases requested by the RACs and their status.
When the team at her hospital started analyzing how the hospital handled external record requests, it determined that departments tended to operate in silos and there was a lot of duplicate effort.
"We used the weeks before the first RAC requests arrived to reflect on our current way to doing business and to determine how we could get the job done with the resources we had," she says.
Develop policies, procedures
Dempsey advises hospitals to create a RAC committee and develop policies, procedures, roles, and responsibilities for the RAC project.
Meet regularly even if you are not currently part of the RAC program, she adds.
"Conduct mock RAC audits to test the entire process and test the RAC electronic database to make sure it will work smoothly when the going gets rough," Dempsey says.
Ensure that all stakeholders work together in all external audits and medical records requests, she says.
"In the past, audits were the problem of finance, and operational issues were the problem of operations. That's not the case anymore. You need to have cross-organization representation and ownership," Dempsey says.
Make sure everyone on your team understands the five stages of Medicare appeals and is clear on the definition of all the terms involved in the RAC process, says Delilah Dennis, RN, QIO liaison at Bay Medical Center in Panama City, FL.
"When the requests for records come rolling in, everybody on the RAC team needs to be on the same page," she says.
Review the DRGs the RACs targeted in the pilot project, along with applicable coding guidelines, assess your vulnerability to denials, and make corrections, suggests Bridgette Kreuder, RN, CCS, director of quality, coding, and appeals for North Shore-Long Island Jewish Health System.
Check your RAC vendor's web site regularly for updates on the issues it is looking for in the audits, Kreuder suggests.
"CMS is requiring the vendors to be transparent during the permanent audits. They are required to identify the issues they're going to be focusing on," she adds.
Designate someone to review the charts before they're sent out to make sure they are complete and include all Important Messages from Medicare along with other documentation, Dennis recommends.
"Every time a chart is requested, it will take a road trip and may be reviewed by other government organizations. It's important that you send out everything in the chart," she says.
Keep track of the number of pages you copy, Dennis suggests.
"At 25 cents a page, this can add up. If you include the number of pages you are sending, the RAC will reimburse you," she says.
Keep back copies of the InterQual manuals and copies of the Medicare inpatient-only list handy, Dennis suggests.
"In the demonstration project, the RAC denied a lot of stays based on current InterQual criteria when they met inpatient criteria in the year in which they took place. We were able to successfully appeal by referring to InterQual criteria that applied at the time of the admission. The same was true for procedures that were on Medicare's inpatient-only list," she says.
Always appeal
Appeal the RAC denials no matter what, suggests Deborah Mallon, RN, MPA, CCS, assistant vice president, clinical documentation management, North Shore-Long Island Jewish Health System.
"Even if you think you're wrong, appeal anyway. RAC has denied claims that were not appropriately denied. In the demonstration program, a good percentage of the appeals were decided in favor of the provider," Mallon says.
This means having a system and enough staff to handle the volume of record requests your hospital is likely to get, she adds.
The hospital system still is appealing 21 denials for reimbursement of implantable defibrillation devices from the demonstration project. Kreuder and a physician are traveling to Ohio to meet with the administrative law judge on the appeals.
"The RACs claimed that these could safely be done on the outpatient side, but our patients were extremely ill and the physicians' judgment that the procedures needed to be performed in the inpatient setting to ensure that the patients were safe," she says.
Before the Recovery Audit Contractor (RAC) issued its first requests for data, Sharp HealthCare in San Diego assembled a committee of stakeholders to determine what the process would probably be like, how to track requests, how to ensure that the health system responded in a timely manner, and what the appeals process should be.Subscribe Now for Access
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