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RAC Reform Movement Gains Some Traction

Joe Cantlupe, for HealthLeaders Media, March 28, 2013

Physicians and their hospital leadership should look at some elements to avoid problems with government audits, especially RACs. Among the recommended checkpoints:

  • Examine potential physician self-referral
    Hospital leadership should "look carefully at categories of payments that may be considered as Medicaid overpayments" related to providing incentives to physicians, or self-referrals, Elion says. Those areas could be violations of the Stark Law, "for services induced by kickback, (or related) to drug and medical device company payments to physicians," he adds.

Also, Elion advises that hospitals check the Office of Inspector General's list of excluded individuals and entities before making new hires. Every six months that list should be reviewed, to avoid the risk of receiving payment for services ordered or provided by an excluded provider, he says.

  • Establish a tracking system on RAC requests for reviews
    Elion says hospital leaders should familiarize themselves with various state limits on how many records and how often they would be reviewed by RAC. He says that authorities should especially review Medicare claims that already have been audited, or ones that are more than three years old, to assure accuracy of the data.
  • Establish a Comprehensive Clinical Documentation Program
    Such a program would ensure "complete and accurate clinical documentation," Elion says. Hospitals "are scared and got too conservative with their billing and only hurt themselves," he adds. "That's what I think is happening. They are so afraid of the headlines, so afraid of the newspaper, so afraid of treble damages," he says.

"I maintain hospitals should be paid fairly for the work they did," Elion adds. "Hospitals are finding themselves in a dilemma."

That may be putting it mildly. Some would say they are finding themselves in a vise.


Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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