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AHA RAC Program Update Answers Provider Questions

Andrea Kraynak, for HealthLeaders Media, October 13, 2009

As of September 18, all four RACs were conducting automated audits, according to an October 6 American Hospital Association (AHA) RAC program update. But only 16 of the 23 audits underway were on hospital outpatient claims, according to the AHA. (The others were therefore on physician and durable medical equipment claims.)

So unless your hospital is so very unlucky to have been selected as one of the first for an audit, chances are you still have time to make a few necessary tweaks and run a few tests on your RAC processes to help ensure you're ready when RACs do begin auditing your facility.

The AHA also updated providers on the arrival of additional types of RAC audits (e.g., DRG validation and medical necessity). RACs have already requested the ability to audit for more than 100 different issues, according to the AHA. Some of these include code and DRG validation reviews, which CMS has not yet approved, choosing instead to begin solely with automated audits involving no need for medical record review.

And while DRG and coding reviews could begin as soon as November, the AHA says CMS may delay the onset of medical necessity reviews so it can first establish a process that would give providers the ability to re-bill all eligible outpatient claims. CMS previously announced medical necessity reviews would begin in January 2010.

The AHA update also addressed the problems with the current remittance advice process. According to the update:

"CMS is aware of several problems with the current process that prevent claim-level reconciliation by hospitals…  Instead of claims-level detail, the remittance advice combines information on all recoupments occurring on a particular day into a single batched amount. The lack of claim-level data on the remittance advice at the point of recoupment prevents hospitals from reconciling anticipated recoupments with actual recoupments."

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