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RAC Nightmare Continues for Providers

Rene Letourneau, for HealthLeaders Media, September 16, 2013

'A Proven Revenue Source for CMS'
"It is frustrating to have significant dollars taken back based on an auditor's retrospective review of the provider's delivery of care based on their professional judgment at the time," she says. "… [T]he auditor has benefit of hindsight and the documentation that becomes available after the intervention and hospitalization has occurred and the outcome at discharge is known… It is particularly frustrating because the dollars have already been expended on taking care of those patients."

Southwest General is tackling the RAC challenge by making efforts to improve clinical documentation, tightening up internal controls, and using an outside service to review its inpatient Medicare cases. But all of that comes at a price.

"We have added charge capture specialist positions that assist with denial prevention. Other than that, the cost to the program is really the opportunity cost of having our director of HIM, case management, revenue cycle, vice president of medical affairs, and others reviewing denials and working with our largely independent medical staff on documentation improvement. Another hard cost is the fees we pay to an outside agency to review nearly all of our Medicare admissions for medical necessity," Freas says.

"We don't expect this process to go away," she adds. "It's a proven revenue source for CMS."

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3 comments on "RAC Nightmare Continues for Providers"


Jeff Angel (9/23/2013 at 8:17 PM)
This will continue until organized medicine makes a stand. I dont know why we are cowering down to cms and auditors over this blatant money grab from hard working people. We all need to just say no!!!!!! MPHs need to help us figure this out[INVALID][INVALID]penalizing hard workers with post audits when we dont know rules is one of yhe most stressful things in medicine. Another reason for smart kids to go into medicine. If we have surgeons in 20 years it wi be a miracle!!!!!

Ronald Hirsch (9/19/2013 at 2:53 PM)
RAC's claim they are fighting fraud and that RACTrac data is faulty and self-selected http://goo.gl/Yf6GJU yet they have only found 8 cases of fraud in 7 years. Irony at its best

daniel dulnikowski (9/16/2013 at 8:20 PM)
We were hit with three a few months ago. Two Breast Cancer patients, and an Ovarian Cancer patient. All had Lymphedema, and needed compression pumps. I looked and the paperwork and it was all solid. One had already be fought to the ALJ level, and won. We submitted our paperwork, and LOST. Two of these patients shoudl be covered under the Women's Cancer Health Act of 1998. But they were denied anyway. If they can do it to these patients, they can do it to anybody.