Author Archive for: The RAC Report
Essential questions every HIM director should ask about RAC record requests
June 25th, 2009 
When planning for RAC record requests, HIM directors should ask the following questions:
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What is our volume of claims that fall under each RAC-identified issue? Once RACs begin posting the issues they intend to audit on their Web sites, determine whether your hospital’s volume in these areas (e.g., one-day stays) is high, says Camille Cohen, MBA, MSW, CHC, compliance solutions manager at 3M Health Information Systems in Salt Lake City. Your claims might be compliant, but a RAC could still request a large number of records because of your high volume. Responding to the requests could have considerable operational ramifications, including having to track and respond to those requests, she says.
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Do we need to hire additional staff members? This is a difficult question to answer for HIM directors, primarily because record requests could arrive arbitrarily or separately throughout a 45-day period. Because of the inconsistency, assessing whether an additional staff member is needed may be difficult, says Cohen. However, directors can and should begin to track the timing of requests upon receipt. “Initially, you may see more sporadic requests because the RACs are gearing up. After that, there may be more of a pattern to it,” she says. And don’t be afraid to seek help outside the HIM department. “There may be some function that you can off-load during a high peak time,” she says. Consulting firms you have worked with in the past may be another option.
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Will we require staff members to review records before we send them to the RAC? Reviewing records before staff members send them to the RAC adds processing time, but is wise because it helps ensure that the response is complete and no documentation is missing, says Cohen. This extra step also helps identify potential inaccuracies before the RAC does.
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Who will we assign to process record requests? Identifying the individual who will receive record requests is important to ensure compliance with the 45-day response time, says Cohen. Directors should pay close attention to the initial letter because RACs will use it to communicate the specific request limit for each organization. Hospitals may identify the designated contact person by registering this information on their RAC’s Web site. Create a process and assign a backup contact person for days when the designated individual is out of the office, says Cohen. In addition, some hospitals may decide to use a post office box for all RAC-related communications. Currently, RACs will communicate with hospitals via the U.S. Postal Service only. Using a post office box can help prevent lost and misplaced letters in a busy mailroom.
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Will we monitor the total number of requests we receive every 45 days? RACs may request a maximum of 200 records every 45 days, so ensure that they don’t exceed this limit is important. “In the demonstration program, some of the RACs made mistakes,” Cohen says.
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Which format should we use when responding to record requests? CMS requires that RACs have the ability to accept paper records and scanned images on a CD or DVD. Beginning in 2010, RACs must also accept imaged records electronically, according to the advisory. Hospitals must decide which (e.g., paper, DVD, or CD) is most feasible. This decision is particularly important for hospitals with a hybrid paper and electronic record, says Cohen. Sending your record in more than one format is inadvisable because it requires that someone outside your hospital is responsible for combining information. “Either print your electronic or scanned record or scan your print copy so you can ensure everything is together before sending it to the RACs,” Cohen says.
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Will we retain a copy of records we send to the RACs? Retaining a copy of records you’ve sent to your RAC can be helpful in case the RAC doesn’t receive them and when appealing denials, says Cohen. Hospitals should ensure that they store copied information securely, regardless of whether it is a paper duplicate or a scanned image, she says.
Editor’s note: This article is excerpted from the July issue of Medical Records Briefing.
Q&A: RACs and physician offices
June 25th, 2009
Q. Our Midwestern physician practice that has more than 30 physicians. Are physician offices “vulnerable” or on the radar for RACs?
A: Yes, they are vulnerable. In addition, CMS has stated that when a RAC denies a hospital stay or service for medical necessity, the associated physician services would also be subject to denial.
Editor’s note: Tanja Twist, director of Patient Financial Services at Methodist Hospital of Southern California answered the previous question. She will also be speaking in the upcoming HCPro audio conference, “Medicare Appeals: Practical and Compliant Procedures for Overturning Denials,” as well as at the upcoming conference, “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors,” which will be held in Atlanta this October.
Hospital shares experience, tips for surviving RAC audits
June 25th, 2009
One of the best ways to prepare for a RAC audit comes in learning from survivors. Elizabeth Lamkin, CEO of Hilton Head Regional Hospital in South Carolina, offered guidance to HFMA’s ANI conference attendees on June 15 on how to prepare for RACs.
As part of the RAC demonstration program, Hilton Head Regional, a Tenet Healthcare hospital, was audited and subsequently went through the appeals process.
During the audit, Lamkin says the hospital was very detailed in its record keeping. "We kept a copy of everything we sent. We also reviewed every chart for compliance with our physician advisor, and were confident we had medical necessity so we appealed," she says. On the 31 charts involved in the audit, Lamkin says the hospital received 22 back saying they had been denied. "They were bounty hunters. They want your scalp," she says.
In preparing for RACs, Lamkin says it is essential for hospitals to have the right physician advisor in place to monitor medical necessity cases. At Hilton Head Regional, the chief of staff works part time as a physician advisor. "If done correctly, a physician advisor will be your saving grace," says Lamkin. "If the patient does not meet medical necessity, the call goes to the physician advisor, so it means your case managers and that doctor have to get along."
The hospital also started using a call center two years ago to advise physicians on the proper bed status of patients presenting in the emergency room. The hospital also does real-time billing audits and compliance checks on the front end.
Editor’s note: This article was excerpted from the HealthLeaders Media article “From HFMA: Preparing for a RAC Audit."
Q&A: Reimbursement for RAC medical record copying costs
June 25th, 2009
What is our volume of claims that fall under each RAC-identified issue? Once RACs begin posting the issues they intend to audit on their Web sites, determine whether your hospital’s volume in these areas (e.g., one-day stays) is high, says Camille Cohen, MBA, MSW, CHC, compliance solutions manager at 3M Health Information Systems in Salt Lake City. Your claims might be compliant, but a RAC could still request a large number of records because of your high volume. Responding to the requests could have considerable operational ramifications, including having to track and respond to those requests, she says.
Do we need to hire additional staff members? This is a difficult question to answer for HIM directors, primarily because record requests could arrive arbitrarily or separately throughout a 45-day period. Because of the inconsistency, assessing whether an additional staff member is needed may be difficult, says Cohen. However, directors can and should begin to track the timing of requests upon receipt. “Initially, you may see more sporadic requests because the RACs are gearing up. After that, there may be more of a pattern to it,” she says. And don’t be afraid to seek help outside the HIM department. “There may be some function that you can off-load during a high peak time,” she says. Consulting firms you have worked with in the past may be another option.
Will we require staff members to review records before we send them to the RAC? Reviewing records before staff members send them to the RAC adds processing time, but is wise because it helps ensure that the response is complete and no documentation is missing, says Cohen. This extra step also helps identify potential inaccuracies before the RAC does.
Who will we assign to process record requests? Identifying the individual who will receive record requests is important to ensure compliance with the 45-day response time, says Cohen. Directors should pay close attention to the initial letter because RACs will use it to communicate the specific request limit for each organization. Hospitals may identify the designated contact person by registering this information on their RAC’s Web site. Create a process and assign a backup contact person for days when the designated individual is out of the office, says Cohen. In addition, some hospitals may decide to use a post office box for all RAC-related communications. Currently, RACs will communicate with hospitals via the U.S. Postal Service only. Using a post office box can help prevent lost and misplaced letters in a busy mailroom.
Will we monitor the total number of requests we receive every 45 days? RACs may request a maximum of 200 records every 45 days, so ensure that they don’t exceed this limit is important. “In the demonstration program, some of the RACs made mistakes,” Cohen says.
Which format should we use when responding to record requests? CMS requires that RACs have the ability to accept paper records and scanned images on a CD or DVD. Beginning in 2010, RACs must also accept imaged records electronically, according to the advisory. Hospitals must decide which (e.g., paper, DVD, or CD) is most feasible. This decision is particularly important for hospitals with a hybrid paper and electronic record, says Cohen. Sending your record in more than one format is inadvisable because it requires that someone outside your hospital is responsible for combining information. “Either print your electronic or scanned record or scan your print copy so you can ensure everything is together before sending it to the RACs,” Cohen says.
Will we retain a copy of records we send to the RACs? Retaining a copy of records you’ve sent to your RAC can be helpful in case the RAC doesn’t receive them and when appealing denials, says Cohen. Hospitals should ensure that they store copied information securely, regardless of whether it is a paper duplicate or a scanned image, she says.
June 25th, 2009
Q. Our Midwestern physician practice that has more than 30 physicians. Are physician offices “vulnerable” or on the radar for RACs?
A: Yes, they are vulnerable. In addition, CMS has stated that when a RAC denies a hospital stay or service for medical necessity, the associated physician services would also be subject to denial.
Editor’s note: Tanja Twist, director of Patient Financial Services at Methodist Hospital of Southern California answered the previous question. She will also be speaking in the upcoming HCPro audio conference, “Medicare Appeals: Practical and Compliant Procedures for Overturning Denials,” as well as at the upcoming conference, “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors,” which will be held in Atlanta this October.
Hospital shares experience, tips for surviving RAC audits
June 25th, 2009
One of the best ways to prepare for a RAC audit comes in learning from survivors. Elizabeth Lamkin, CEO of Hilton Head Regional Hospital in South Carolina, offered guidance to HFMA’s ANI conference attendees on June 15 on how to prepare for RACs.
As part of the RAC demonstration program, Hilton Head Regional, a Tenet Healthcare hospital, was audited and subsequently went through the appeals process.
During the audit, Lamkin says the hospital was very detailed in its record keeping. "We kept a copy of everything we sent. We also reviewed every chart for compliance with our physician advisor, and were confident we had medical necessity so we appealed," she says. On the 31 charts involved in the audit, Lamkin says the hospital received 22 back saying they had been denied. "They were bounty hunters. They want your scalp," she says.
In preparing for RACs, Lamkin says it is essential for hospitals to have the right physician advisor in place to monitor medical necessity cases. At Hilton Head Regional, the chief of staff works part time as a physician advisor. "If done correctly, a physician advisor will be your saving grace," says Lamkin. "If the patient does not meet medical necessity, the call goes to the physician advisor, so it means your case managers and that doctor have to get along."
The hospital also started using a call center two years ago to advise physicians on the proper bed status of patients presenting in the emergency room. The hospital also does real-time billing audits and compliance checks on the front end.
Editor’s note: This article was excerpted from the HealthLeaders Media article “From HFMA: Preparing for a RAC Audit."
Q&A: Reimbursement for RAC medical record copying costs
June 25th, 2009
June 25th, 2009
Q: If you submit requested medical records to RACs via CD, are you still reimbursed copying costs (i.e., 12 cents per page)?
A: Yes. You will be reimbursed for copying costs regardless of whether you send in paper copies or images on CD or DVD.
Editor’s note: Thanks to Nancy Hirschl, BS, CCS, president of Hirschl & Associates in Laguna Niguel, CA, for answering this question.
Have a RAC Question? CMS Has Some Answers
June 11th, 2009
While none of the newest RAC FAQ released by CMS-it published 15 in the last week-are particularly surprising, they are perhaps a sign that CMS is continuing to make every effort to share RAC information providers need to know through as many channels as possible.
It may be sharing the same information during RAC outreach sessions or during Open Door Forum calls, but now the information is also readily available to those who wish to learn about RACs in a Q&A format.
The new or updated questions include the following:
- What is the reimbursement procedure and rate for photocopy charges associated with records for RAC audits?
- How will the RACs determine which claims to review?
- Whose claims will be reviewed under the RAC program?
- Under what circumstances can a RAC, make a finding that an overpayment or underpayment exists without requesting medical records?
- Under what circumstances will a RAC request medical records in order to determine if an overpayment exists?
- How long does a provider have to submit medical records when requested by a RAC?
- Do RACs look for underpayments? What happens if they find an underpaid claim?
- How are the RACs paid for finding underpayments?
- If a provider repays or Medicare recoups an alleged overpayment identified by the RAC and the provider later wins an appeal, will CMS reimburse the provider with interest?
- Will the RAC review evaluation and management services on outpatient hospital claims?
- Will the RACs replace all current review entities?
- Will the timing for appeals by the Medicare contractors be the same for the RACs?
- How are the RACs paid for finding and recovering overpayments?
- Will the RAC appeal process mirror the regular Medicare appeal process?
- How will the RACs choose the healthcare entity that is to be reviewed for over- or underpayments? Will it be a random process?
The entire list of questions is available on the CMS Web site.
If you have a RAC question for CMS you have yet to have resolved, perhaps now is a good time to send in your question--CMS may just be in the mood to answer 15 more questions this week.
Take our survey; Be part of a comprehensive look at national RAC preparedness
May 28th, 2009
We invite you to take our comprehensive survey on what your facility is doing to prepare for the permanent RAC program. It should take approximately 10 minutes to complete.
We value your input and appreciate your time and effort in completing this anonymous survey. As a thank you, we will be happy to send you our completed benchmarking report detailing the results of the survey. To receive your free copy of the benchmarking report, you will have the opportunity to separately request one upon completion of the survey. Thank you for your time and consideration.
To participate in the survey, click here.
RACs and Medicare Advantage
May 28th, 2009
We invite you to take our comprehensive survey on what your facility is doing to prepare for the permanent RAC program. It should take approximately 10 minutes to complete.
We value your input and appreciate your time and effort in completing this anonymous survey. As a thank you, we will be happy to send you our completed benchmarking report detailing the results of the survey. To receive your free copy of the benchmarking report, you will have the opportunity to separately request one upon completion of the survey. Thank you for your time and consideration.
May 28th, 2009
Q: Are the Medicare Advantage plans included in RAC audits?
A: According to Section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Medicare Advantage plans are not included in RAC audits. They are exempt from the RAC program, as the RAC is focusing on Part A & Part B providers.
According to the RAC Status Document FY 2006:
Section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (see Appendix A) directs the Secretary of the U.S. Department of Health and Human Services (HHS) to demonstrate the use of Recovery Audit Contractors (RAC) in:1) Identifying Medicare underpayments and overpayments; and2) Recouping Medicare overpayments.Under the demonstration, the Centers for Medicare & Medicaid Services (CMS) pays the RACs on a contingency basis; that is, the RACs receive a portion of what they identify and collect. The demonstration program is designed to determine whether the use of RACs will be a cost effective means of adding resources to ensure correct payments are being made to Medicare providers and to ensure that taxpayer funds are used for their intended purpose. The legislation requires the Secretary to conduct the demonstration for payments made under part A or B of Title XVIII of the Social Security Act (i.e., traditional fee-for-service (FFS) Medicare). Thus the RAC demonstration does not include the audits of payments for Medicare Part C (managed care) or Part D (the prescription drug benefit).
Editor’s note: Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City answered this question.
Master wound care coding to prepare for RAC audits
May 28th, 2009
Coders should arm themselves with as much wound care and coding knowledge as possible to prepare for anticipated RAC audits, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, senior corporate director of coding and HIM compliance at Catholic Healthcare West in San Francisco.
That means understanding the clinical difference between excisional and nonexcisional debridement, knowing what documentation is required to support each procedure, and proactively educating physicians and other staff members who perform these procedures about what they need to document in the medical record.
Bryant also offered a few suggestions on how to prepare for the RACs that may target this area of coding:
- Reviewing all Coding Clinic guidance dating back to the 1980s. Guidance regarding wound care coding has changed many times since Coding Clinic offered initial advice in 1988. Since then, it has published nine more clarifications. The most recent guidance came in Coding Clinic, in the third and fourth quarters of 2008.
- Implement standardized processes for documenting debridement. Pay particular attention to excisional debridement, as it typically falls under a higher-paying MS-DRG. During the demonstration project, the RACs focused on insufficient terminology in documentation.
- Track debridement cases at your facility. Especially focus on cases for which coders assign ICD-9 procedure code 86.22. Bryant said she started doing this in a homegrown spreadsheet within her system and continues to use coding compliance software to track this procedure information.
- Audit a random sample of patients coded with 86.22. Look for coding errors and fix any inaccurate claims. However, don’t change documentation in a medical record to prove excisional debridement, Bryant said. During a CMS RAC Open Door Forum in 2008, Bryant asked for clarification about how far back hospitals can change medical records. CMS responded that hospitals may amend documentation “in a timely manner,” but did not provide more information. Bryant urged caution here.
- Suggest the need for a standardized appeal letter. If the RAC claims that documentation in a medical record does not support ICD-9-CM procedure code 86.22, but you believe it does, “go back, look at the policy, look at the documentation, and appeal that case,” Bryant said.
Editor’s note: This tip was excerpted from the article “Understand inpatient wound care coding for RAC audits,” published in the May issue of Briefings on Coding Compliance Strategies. For more information on the audio conference, “ICD-9-CM Procedural Coding for Wound Care and Debridement: Confront Compliance and RAC Challenges,” visit HCMarketplace.
