Nov

12

Manage your fear of RACs

By Case Management Weekly

CMS’ RAC program may elicit feelings of fear, but Brenda Keeling, RN, CPHQ, CPUR, president and owner of Patient Response in Milburn, OK, says it is the last thing you should feel when faced with a RAC audit.

Remember that RACs cannot randomly select claims or target one “solely because it is a high-dollar claim,” according to the draft Statement of Work. A RAC can only “target a claim because it is a high-dollar claim and contains other information that leads the RAC to believe it is likely to contain an [over- or underpayment].”

Nancy Hirschl, BS, CCS, president of Hirschl & Associates in Laguna Niguel, CA, and advisory board member for HCPro, Inc.’s e-newsletter The RAC Report, says the “other information” could include:

• Diagnosis codes that may be incorrectly coded based on RAC experience in the private health insurance arena
• Diagnoses that often present physician documentation insufficiencies
• Procedure codes that do not correlate with diagnosis codes
• Procedure codes that may indicate inappropriate site of service/inpatient status
• Incongruent charge to payment comparison
• The belief that the claim payment was not consistent with Medicare payment policy

Hirschl says you should identify areas the RAC may target before the RAC arrives, develop strategies to defend your data, and improve case management protocols.

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