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7 Tips for RAC Region D Providers

 |  By jcarroll@hcpro.com  
   August 30, 2010

Let's face it—dealing with Recovery Audit Contractors RACs is an albatross around the neck of susceptible providers. But for diligent hospitals that have anticipated RACs since the demonstration project, the situation is far less dire.

A recent update to the evaluation of the RAC demonstration shows that HealthDataInsights (HDI), the RAC for Region D, had the highest percentage of claims overturned on appeal, which shows that, like providers, HDI is not perfect.
With this in mind, consider the following tips to help develop a conscientious approach from start to finish, which can augment providers' chances of success throughout the RAC process.

  1. Know your number limit when it comes to medical record requests. Based on the current formula, limits are based on the servicing provider's tax identification number and the first three positions of their ZIP code; and set at 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days), according to Jennifer McManis, RHIT,  the compliance/privacy officer at Bozeman Deaconess Hospital in Bozeman, MT.

  2. Develop an audit tool. When it comes to medical records and their related claims, this is a must, according to McManis. "The tool should focus on appropriate DRG assignment, appropriate assignment of complications/comorbidities, appropriate principal procedure assignment; and the coding source," she says. "In addition, it should address discharge disposition validation and medical necessity validation."  
  1. Determine what you are going to review. The timeline is short for appealing unfavorable findings, so reviewing all the records before the request may not be possible, says McManis. "Review the data that is already out there," she says. "Identify where your facility may be an outlier for areas that are considered at risk, such as chest pain, stroke, one-day stays, and so on."

  2. Use the discussion period. This period of time was implemented by CMS as a way for providers to have an open discussion about how a RAC may have made a determination, and allows the provider to offer additional information, according to Debbie Mackaman RHIA, CHCO, regulatory specialist for HCPro, Inc. "This is a valuable resource for providers looking to avoid the appeals process," she says.

  3. Know how and when to appeal RAC determinations. A facility's RAC team should determine which charts contain documentation to support the appeal, according to Mackaman. "This requires expertise from all areas of your team," she says. "In addition, request the credentials of the HDI review staff, and request to talk to the contractor medical director, when appropriate."

  4. Develop a letter template. Use the letter—which should contain the complete information needed—at every level of appeal for consistency, and provide explicit detail to support your position, according to Mackaman. "Be sure to include the judgment of the admitting physician and a letter supporting medical necessity," she says. "This will also help with keeping inside the timelines, which need to be monitored. If a deadline is missed, your appeal is finished!"

  5. Develop a tracking tool. This tool, which should track all aspects of the RAC process from additional documentation requests to the resolution, needs to cover the who, what, where, when of a decision, according to Mackaman. "Pay attention to the details here, and don't just count on your memory!" she says. "There is no such thing as being over-preparedness when it comes to the RAC process."

 

Debbie Mackaman RHIA, CHCO, and Jennifer McManis, RHIT are speaking in the September 21, 2010 audio conference: RAC Audits in Region D: Strategies for success under HDI.

James Carroll is associate editor for the HCPro Revenue Cycle Institute.

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