Hospital’s proactive approach to RAs pays off

All admissions are reviewed

A proactive approach to the Recovery Auditor (RA) process has paid off for Alamance Regional Medical Center in Burlington, NC. Out of more than 800 denials from the auditor, the hospital has appealed up to the administrative law judge level, if necessary. So far, the hospital has won a high percentage of the appeals. Many are still pending because of a backlog.

“My goal is not to lose. We appeal 100% of denials, and we don’t accept no for an answer,” says Anne Brewer, RN, BSN, CCM, denial audit coordinator at the 238-bed regional medical center.

Brewer attributes the hospital’s success during the audit process with the approach the hospital leadership took when the Centers for Medicare & Medicaid Services first announced the Recovery Auditor program.

The hospital created a new utilization review department to perform reviews on all admissions to make sure they meet admission criteria, no matter where they come into the hospital. In addition, the hospital assigned care coordinators to the emergency department from 3 a.m. to 11 p.m., seven days a week, to work with physicians on medical necessity and admissions status. The nurse care coordinators in the emergency department have received extensive training on InterQual criteria and updates as well as on hospital admission policies.

In addition, a utilization manager conducts a pre-surgical review to make sure the documentation is complete on all patients having elective surgery before the surgery is performed and reviews all surgical cases after the surgery to determine if surgical complications indicate medical necessity for an overnight stay.

“We are on it [medical necessity] as soon as the patients hit the door. We try to cover all the bases,” Brewer says. The utilization manager meets with the admitting physicians if there are questions about medical necessity or patient status. If the question is not resolved, the case is sent to the physician advisor firm under contract with the hospital. The secondary physician advisor reviews the case and calls the admitting physician to discuss it before making a final determination if more documentation is necessary.

The team members educate the physicians any time they see missing information in the documentation and put up charts in the emergency department to remind staff what details need to be included in the documentation.

“We encourage the physicians to document what they are thinking about the patient’s condition to give the complete picture to justify the orders for inpatient care. We know that if physicians order observation services for every one-day stay, we are doing it wrong,” she says.

The hospital has worked with surgeons to document medical necessity for surgical procedures in the patient record. Most physician offices send over the office notes, including history and physical information as well as outpatient treatments, such as physical therapy, that have failed.

“We’ve had good success with asking for the information. The physicians know that while the RA reviews don’t impact them now, they will in the future,” she says.

Brewer checks the CMS website for updates every day to stay current on what conditions are being targeted for automated audits. She attends seminars and webinars on the RA process, and even follows CMS on Twitter.

Brewer stays on top of the conditions being targeted in Medicare’s three-year Recovery Audit program prepayment review demonstration project and beefs up education on those conditions. Under the program, being conducted in 11 states including North Carolina, the Medicare Administrative Contractors (MACs) review and affirm or deny claims before they are paid. Hospitals may appeal the prepayment denials through the normal appeals process.

“We pay careful attention and we have done a lot of education around syncope because that was the first target for our hospital. We know that prepayment reviews for transient ischemic attacks and gastrointestinal conditions with hemorrhage are on the horizon. During our last RA audit, those were the biggest targets,” she says.

When the RA program (then called the Recovery Audit Contractor Program) began, the hospital purchased computer software to track everything, she says. “We check the CMS website every day so we are not surprised with the cases being pulled for automated audits,” she says.

The team tracks every record request and denial in the computer system and notifies the physician advisor or the outside physician advisory firm, depending on who reviewed the record initially. The hospital files an appeal quickly, using an outside physician advisory firm for the appeals if they reviewed the case originally. Otherwise, Brewer writes the appeals.

“When we get a denial, we have everything ready to go for the first level of appeals and send it out before the 30 days are up. We want to hang onto the money as long as we can,” she says.