You, too, can survive the Recovery Audit Contractors
You, too, can survive the Recovery Audit Contractors
Participants in the demonstration project share their experiences
When Lori Dempsey talks to health care professionals around the country about her experiences with the Recovery Audit Contractors (RACs) demonstration project, she opens her presentation by saying: "Are you nervous? Are you frustrated? Are you anxious about the RACs? Well, I'm here to legitimize all of those concerns."
Dempsey, vice president of financial compliance at Lutheran Medical Center in New York City, makes the comments to make people laugh but adds that dealing with the RACs is no laughing matter, particularly if you aren't prepared.
Other representatives from hospitals in Florida, New York, and California — the three states in the RAC demonstration project — advise that putting a strong emphasis on getting patient status and documentation right on the front end and getting organized before the RACs start requesting medical records is the best way to get the audit process off to a good start.
Make no mistake, the RAC process is time-consuming and burdensome, they say, but if you plan in advance, pay attention to detail, and appeal your denials, you can limit your hospital's vulnerability to losing revenue.
Appealing denials: What you can expect
Financial and case management representatives interviewed by Hospital Case Management about their RAC demonstration project experiences reported appealing nearly 100% of RAC denial with a high success rate, exceeding 90% in some facilities.
"In the pilot project, the RACs were incentivized to issue denials and took a shotgun approach. Based on what we have seen from the Centers for Medicare & Medicaid Services [CMS], there will be more structure in the permanent RAC initiative, including a medical director and nurses who review the cases," says Debra Brockmeyer, BSN, RN, CPUR, division director of case management, East Florida division, HCA Healthcare, with headquarters in Fort Lauderdale.
Under the permanent RAC project, hospitals are going to be less likely to win on appeal because the auditors are reviewing the files, not just data mining, she adds.
This means that hospitals need to make sure the documentation is complete and correct, Brockmeyer says.
Excellent documentation won't help hospitals avoid a RAC review, but it will help limit the amount of effort staff have to put into a review, she points out.
"If the documentation is not adequate, you have to do the chart all over again and then you have duplication of effort," she says.
As a result of the RAC pilot project, the HCA division has become more focused on what the case managers are writing in the documentation to avoid doing re-reviews.
Documentation must be specific
"We want to be very specific in our documentation, instead of writing a rambling narrative. We've beefed up our interrater reliability review process and talk in every staff meeting about getting the documentation right the first time," Brockmeyer says.
The people who are handling the hospital's RAC process should work very closely with the hospital's clinical documentation program, advises Dempsey, who was in charge of compliance at a larger New York institution with more than 1,176 beds when the RAC demonstration project was rolled out.
"At the time I was developing the RAC committee, the organization was rolling out its clinical documentation program. It couldn't have happened at a better time," Brockmeyer says.
Dempsey's former hospital's clinical documentation improvement program was headed by a physician and staffed by nurses.
"In the beginning, the two initiatives were not related, but as the rollout occurred, the two areas became joined at the hip. We saw what the RACs were looking at and initially focused on educating the staff improving documentation in those areas," she recalls.
At that hospital, clinical documentation improvement and appeals management reported to the same physician vice president, who facilitated education of the physicians on how they should document, Dempsey says.
At Sharp HealthCare, a seven-hospital system with headquarters in San Diego, clinical documentation specialists and case managers play a vital role in the RAC process because they are on the unit, interacting with physicians and making sure the documentation is complete and appropriate, says Tony Guerra, CFO for Sharp Coronado, a 204-bed hospital in San Diego.
"The RAC process may be spearheaded by finance, patient access, or health information management, but with the emphasis on one-day stays, case managers have to be in the loop to make sure that medical necessity criteria are met up front and that patients are in the appropriate status," Guerra says.
As a result of its experience with the RAC pilot project, HCA's East Florida division beefed up the front end of its processes, putting more emphasis on applying medical necessity criteria whenever patients come in the door, whether it's through the emergency department, direct admissions, or rollovers from same-day surgery, Brockmeyer says.
"We always had strong case management in this division, but with the RAC pilot project, we became acutely aware that we have to get it right up front," Brockmeyer says.
At the same time, the division set a goal of maintaining the same 1:25 case manager-to-patient ratio on weekends as it has during the week to ensure that all patients meet medical necessity criteria and are in the right status.
"A lot of patients who come in late in the week are not staying until Monday. If you don't have them in the right status and are short of staff on the unit, you create a situation that is vulnerable to RAC denials," she says.
Add observation managers
The division has always had emergency department case managers as well as unit-based case managers and has added dedicated observation case managers in every hospital.
The observation case managers' sole responsibility is to review patients in observation and ensure that they move through the continuum as quickly as possible. They cover the larger hospitals seven days a week and work Monday through Friday in the smaller hospitals.
The observation case managers are responsible for pulling a list of all patients in observation every morning and reviewing them every two hours to ensure that they belong in observation and focus on what needs to be done to move them to another level of care or discharge them as quickly as possible.
For instance, if the physician writes in the chart that the patient can be discharged after a repeat chest X-ray, the case manager calls radiology and asks them to complete the procedure as quickly as possible, then makes sure the physician gets the results in a timely manner.
They use a real-time dashboard that shows patients in observation concurrently. The case managers document on the dashboard twice a day, listing barriers to getting patients out of observation within 24 hours.
"We have very definite criteria for moving patients to the inpatient setting. We no longer automatically roll patients over into acute care if they have been here longer than 28 hours. We make sure that all patients who are admitted as an inpatient meet criteria," she says.
The average divisionwide is 25.6 hours in observation for Medicare patients.
Likewise, St. Vincent's Healthcare in Jacksonville, FL, added positions as a result of the RAC process, says Jamie Buller, LCSW, director of case management for the two-hospital health system, which includes St. Vincent's Medical Center with 518 beds and St. Luke's Hospital, which is open for 145 beds.
Buller got additional FTEs approved for a dedicated case manager to review new admissions that are likely to be one-day or two-day stays.
The admissions case managers work from 1:30 p.m. to midnight seven days a week and review new admissions based on the expected length of stay and feedback from the emergency department case manager.
For instance, a Medicare patient with a fractured hip would be a low priority because the length of stay would likely exceed two days and the unit case manager would pick up the review and the care coordination.
"They review for status and to make sure the patients meet criteria. If there is a question, they consult with our external physician liaison company for a review and the company issues a determination letter," Buller says.
The hospitals' unit-based case managers also are responsible for discharge planning, assessment, and care coordination as well as medical necessity review.
"It wasn't unusual for patients to be admitted one morning and discharged later that day or the next morning before the case managers could review the chart. I had no problem getting the new positions approved because of the RAC's emphasis on one-day stays. I wrote up a justification and had the support of the compliance officer and the auditor. We stressed the importance of getting all reviews done to minimize risks and it was easily approved," Buller says.
The admissions care manager tasks all of the cases that don't meet InterQual inpatient criteria to an external physician liaison company, which makes a determination.
"Because of the volume of patients, the day care manager in cardiology can get the reviews done and tasked to the physician liaison company but the determination doesn't always come in by the time she leaves. Now the admissions review case manager can pull the chart and get the order correct by midnight," she says.
During the demonstration project, the RACs also focused on cardiac procedures, prompting Buller to develop a pilot project in which a case manager worked in diagnostic cardiology to get the status right early on.
The hospital has a large cardiology program that serves patients over a wide geographic area that includes Northeast Florida and Southeast Georgia.
The pilot project was ended after three months because the patients often were transferred to the floor before the case manager had enough information to determine patient status. Instead, the hospital system refined its care management protocol for cardiology, Buller says.
Florida hospitals have received authority from CMS for case managers to assign patient status and take that responsibility away from the physicians.
Sources
For more information on the RAC demonstration project, contact:
- Debra Brockmeyer, BSN, RN, CPUR, Division Director of Case Management, East Florida division, HCA Healthcare, e-mail: [email protected].
- Jamie Buller, LCSW, Director of Case Management, St. Vincent's Healthcare; e-mail: [email protected].
- Kari Cornicelli, CFO, Sharp Grossmont, e-mail:[email protected].
- Lori Dempsey, Vice President of Financial Compliance, Lutheran Medical Center, e-mail: [email protected].
- Bridgette Kreuder, RN, CCS, Director of Quality, Coding, and Appeals for North Shore-Long Island Jewish Health System, e-mail: [email protected].
- Deborah Mallon, RN, MPA, CCS, Assistant Vice President, Clinical Documentation Management, North Shore-Long Island Jewish Health System, e-mail: [email protected].
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