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4 Ways to RAC-Proof Hospital Admissions

Karen Minich-Pourshadi, for HealthLeaders Media, January 3, 2011

A third of the reimbursements collected in the demo phase of RAC were due to "wrong setting" denials, according to the Center for Medicare & Medicaid Services. This type of denial denotes hospitals that have provided patients with unnecessary care, mainly for keeping patients for overnight care when it was unnecessary. As we embark on a new year, financial leaders should ask everyone on their teams to make a resolution to address these problems before the RAC does it for them.  

To help in this effort, I touched based with Karen Bowden, president of ClaimTrust, a Murfreesboro, TN-based consulting firm, which has worked with several hospitals in the demonstration project to develop RAC-proof admission screening criteria.

With the goal of ensuring consistent admission screening among patients, Bowden suggests hospitals begin by adding the following screening criteria:

  1. Use Medicare's (and any other payer's) published procedures from inpatient only lists.  This will provide case managers with a general guideline on whether a certain condition is acceptable to be rendered as inpatient.
  1. Develop defensible criteria for "gray area procedures" that are sometimes billed as inpatient and other times as outpatient.
  1. Select a case manager(s) to ensure consistent admission practices. This individual should have the authority to override screening criteria when necessary in order to approve inpatient cases on the sole basis that it can be clinically documented.

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