Dead or alive. In other words, was the patient alive at the time that the treatment was allegedly rendered to him or her? “This may seem obvious but in a number of states their system controls process usually takes 3–4 months to identify a patient as deceased,” says Sheehan. “That’s a pretty straightforward issue for the MIC to focus on.” In addition, MICs may look at whether a physician was deceased at the time he or she allegedly wrote an order, he says.

Inpatient at time of ambulatory service. MICs will look for patients who were inpatients at the hospital at the time they were given home healthcare or ambulance trips.

Hysterectomy on male. This is just one example of inconsistent coding, Sheehan says. “There are computerized techniques for identifying things that are impossible or highly unlikely. Hysterectomy on a male is one of them.”

Debridement requiring actual cutting. MICs will look at regulations and statutes and coding guidance, such as Coding Clinics.

Heart failure and shock. For this issue, MICs will look for failure to meet InterQual criteria for inpatient care.

Ambulatory surgery with no complications to justify inpatient stay. “Commonwealth Fund just came out with a ranking of the states on this issue, and some states are better than others. It may not be a bad idea to find out where your state stands and whether this will be an issue,” Sheehan says.

DRG assignment. Take a code pair with pretty clear criteria (e.g., temporary paralysis vs. more permanent paralysis) and examine which code pair you report more often. If you are heavily weighted toward the more expensive and many other hospitals are weighted the opposite way, you might want to take a good hard look, says Sheehan.

Observation beds. This is always a popular issue because Medicaid rules differ by state and also differ from Medicare in most states, explains Sheehan.

Exclusion. “This is my personal prediction… Over the last three years, the OIG has issued guidance on exclusion that says you can’t even have a janitor who is an excluded person working for your organization if you’re getting paid Medicare or Medicaid money,” says Sheehan, who is finding that many providers don’t have the necessary screening in place to prevent employment of persons excluded under state or federal law. “You may want to take a look before the auditors come in at 2 CFR 402.209 which talks about the scope and effect of exclusions. I find in my own work there’s not as much awareness of these issues as there should be. And it’s an easy data run to do if you are a MIC.”

Data mining to uncover potential vulnerabilities is another part of her ongoing preparation. Martin says. She has learned from other payers conducting audits on her facility where some vulnerabilities may exist, so she’s looking at those areas for RACs too, even if they may not have been approved as issues—yet.

Conducting education for her staff members. She presents educational sessions to individual departments, taking care to explain what the RACs are looking for, the department’s role in the process, how to handle any correspondence or medical record requests and other relevant information.

Posting educational information on their hospital’s intranet where staff members can go to find out more information. There, staff members can find helpful links and other info they may need.

Distributing information to physicians. She created a weekly newsletter, “What’s up Doc?” which the medical staffing office faxes to the physician offices. It contains pointers and information specifically for the physicians so their practice can prepare. And she knows they’re reading it. “I get comments back, and they ask for it when they don’t receive the fax each Wednesday.” She also has a physician liaison on their board.