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Region B and D RACs post new issues, all states now approved for audits

The RAC Report — Thu, 29 Oct 2009 05:00:00 +0000

CGI, the RAC for Region B, has posted three new issues for review in Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin. This means CMS has now approved issues for RAC auditing in all states.

The new issues approved for physician and outpatient hospital claim review in these states are:

For more information on these and other issues approved for Region B states, visit the CGI Web site.

In addition, CMS has approved a new issue for DME provider audits in Region D—Knee orthotic bundling. “There are Knee orthotic addition codes that cannot be billed separately due to the fact that they are bundled with the base knee orthotic code or that the addition code is not medically necessary when billed in conjunction with a specific knee orthotic base code,” according to HDI, the Region D RAC.

For more information, visit the HDI Web site.

CMS releases new FAQ on N432

The RAC Report — Thu, 29 Oct 2009 05:00:00 +0000

On October 15 CMS released an FAQ on the appearance of code N432 on remittance advice. The question is as follows:

Will Code N432 appear on the remittance advice for RAC adjusted claims?

Click here to read CMS’ response.

Sneak preview: Comparing appeal rates for RACs vs. claims processing contractors

The RAC Report — Thu, 29 Oct 2009 05:00:00 +0000

Editor’s note: This excerpt is adapted from the soon-to-be-released book, “The RAC Survival Guide: Successful management of Recovery Audit Contractors,” by Kimberly Anderwood Hoy, JD, CPC. Pre-order your copy on HCMarketplace.com.

The high number of claims determinations appealed was a measure of dissatisfaction with the RAC demonstration project. In January 2009, CMS updated the Evaluation Report with appeal statistics through August 31, 2008. By the beginning of 2009, all timely appeals should have been filed, although some claims still in the appeals process remain undecided at various levels of appeal. The January 2009 update indicated that providers appealed 22.5% of all RAC claim determinations. In contrast, CMS reported in the Evaluation Report that providers appealed only 4% of improper payment determinations by claims processing contractors during the same period. With nearly one-quarter of RAC claim determinations appealed—a rate that is five times higher than for typical claims processing contractors—the data seem to indicate provider dissatisfaction with the accuracy of RAC payment determinations.

Type of Reviewer	Percent of Improper Payment Determinations/Denials Appealed by Provider	Percent of Appealed Claims Overturned in Favor of Provider	Percent of All Improper Payment Determinations/ Denials Overturned in Favor of Provider
Claims Processing Contractors¹	4%	59%	2.3%
Recovery Audit Contractors²	22.5%	34%	7.6%

^{1 The Medicare Recovery Audit Contractor (RAC) Program: An Evaluation of the 3-Year Demonstration, June 2008}

^{2 The Medicare Recovery Audit Contractor (RAC) Program: Update to the Evaluation of the 3-Year Demonstration, January 2009}

The rate of determinations overturned on appeal in favor of the provider was also high, indicating that providers’ concerns were not totally without merit. The January 2009 update reported that 34% of appealed claims were decided in providers’ favor. Note that this is lower than the rate of appealed claims overturned in the provider’s favor for claims processing contractors, which CMS has said is 59%. However, combining the much higher rate of appeals for RACs with the high rate of claims overturned in providers’ favor reveals that the percentage of all RAC claim determinations overturned was three times higher than it was for claims contractors. Only 2.3% of all improper payment determinations made by claims processing contractors were overturned on appeal, but 7.6% of all RAC claim determinations were overturned in the provider’s favor on appeal. This 7.6% rate of reversal lends credence to providers’ concerns regarding improper determinations and improper application of Medicare guidelines.

Audits underway, but hospital continues to refine in preparation for RACs

The RAC Report — Thu, 29 Oct 2009 05:00:00 +0000

St. Joseph Medical Center in Houston has been preparing for RACs for months now, says Cucharras Martin, vice president of revenue enhancement at the hospital and chair of the RAC team. But even though she began long ago, it doesn’t mean she and the rest of her RAC team are now just sitting back and waiting for the audits to begin at her hospital.

“We’re still refining,” she says. Even though her processes have been in place for a long time, Martin is continuously tweaking them.

Martin’s RAC team started by outlining process flows, determining the path RAC correspondence would take through the hospital. The team then assigned roles for everyone involved in the process, and determined the necessary timeline for each step. The goal was to have a medical record request fulfilled in 30 days, as opposed to the 45-day deadline set by the RACs.

Martin then decided to test their processes. She took a sample RAC record request letter and, without informing other staff members when it would occur, sent it to her facility. After working the letter through the work flow, the team realized where changes were necessary.

“We found out we really had to have some sort of log where [the RAC team] could sign off on having seen a medical record request,” she says. The log they developed is now in a binder that tracks each step of the process, and requires signoff when each step is completed. There is also a comment section where staff members could record any relevant notes. “If there is a denial, we can go back and see what we initially said for each claim. This helps us track and document that records were reviewed [prior to submitting them to our RAC],” Martin says.

The test was so effective that she plans to do it again soon. The first time around her team learned which time frames worked, and which didn’t. They also learned where they needed additional resources to make the process effective, be it staff time or something as simple as a binder to track the letter’s path. Martin expects additional tests to show her where else their process works well but also where it still needs work, and she knows that now is the time to refine, while her hospital has not yet been audited.

Developing such a process has also helped her hospital deal with other types of audits—not just RACs. They now track all audits. “Now everyone is aware of all of the auditing activity going on,” she says.

Martin is also taking the following steps to prepare:

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.

Martin and St. Joseph Medical Center have been readying themselves for RACs for a long time now, but she laughs when asked about when she may conclude preparations. She won’t finish until the RACs are.

Escalating Medicare and Medicaid auditing on the horizon

The RAC Report — Thu, 29 Oct 2009 05:00:00 +0000

There’s no question that audit activity is escalating and the healthcare provider community needs to find a way to deal with the higher volume of audits and increasing number of auditors conducting them.

It’s no longer just RAC, MAC, CERT, and ZPIC audits looking to ensure the accuracy of Medicare payments. Providers are also subject to increased scrutiny on the Medicaid side, as states are working with the federal government to help reduce payment error rates and recoup overpayments.

Providers in some states may be ill prepared for the increase in audit activity. “Some states have been more aggressive recently and some states have not had the resources to do it. But I think it is going to be a wakeup call in those states where enforcement has not taken place to receive and respond to the audits,” says James G. Sheehan, the Medicaid Inspector General for New York.

“It is very challenging. The audits are stacking up,” according Sarah Kay Wheeler, partner at King & Spaulding LLP in Atlanta. “And add to the list is the Medicare Advantage plans contracting with different groups to conduct independent audits for Medicare Advantage purposes.”

Sheehan agrees that Medicare Advantage auditing is probably on the horizon, and believes providers may also need to watch out for Medicare Prescription Drug Benefit program audits. “I think it is reasonable to expect that the lessons that CMS learns in calculating estimates of improper payments and in auditing will be extended to the Medicare Prescription Drug Program and the Medicare Advantage Program going forward.”

For now, providers should definitely spend time preparing for Medicaid Integrity Contractor audits, as these should begin in all states by the end of 2009.

What will MICs be auditing? It will vary from state to state, of course. But Sheehan believes some of the following may be issues on which MICs will focus, at least at first:

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.”

Feeling overwhelmed? When it comes to MIC audits you may have an ally. In New York, for example, a topic on the table is minimizing the burden on hospitals and other providers . So Sheehan suggests that if you’re overwhelmed and your MIC isn’t responsive, it might be wise to go to the program integrity head in your state. “If you don’t get a positive response from your MIC when you say, ‘Hey, we’ve got 20 audits stacked up here. Can you please take your place in the queue?’ then go back to the state and tell them you need some relief in the short term.”

Editor’s note: Wheeler and Sheehan spoke during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

For additional background information view the April 22, 2009 GAO report “Improper Payments: Progress Made but Challenges Remain in Estimating and Reducing Improper Payments,” visit the GAO Web site.

Los Angeles Medicare Fraud Strike Force lands 20 on trial

Compliance Monitor — Wed, 28 Oct 2009 05:00:00 +0000

The Los Angeles Medicare Fraud Strike Force arrested 20 California residents for their involvement in various Medicare fraud schemes that resulted in over $26 million in fraudulent bills to the Medicare program, according to a Department of Justice (DOJ) press release.

A total of seven cases are pending trial all involving durable medical equipment company owners and marketers who are accused of fraudulently ordering and billing for power wheelchairs, orthotics, and hospital beds.

Since its inception in 2007, the Los Angeles Medicare Strike Force has indicted 331 individuals who collectively have billed the Medicare program falsely for more than $720 million, according to the DOJ.

Video: “60 Minutes” reports on Medicare fraud

Compliance Monitor — Wed, 28 Oct 2009 05:00:00 +0000

“60 Minutes” recently featured a report on how criminals are defrauding Medicare out of billions of dollars every year. To see a short clip from that segment, click here.

CMW sneak peek: The RAC effect: How RACs influence case management

Case Management Weekly — Wed, 28 Oct 2009 05:00:00 +0000

By Loretta Sandy, PhD, RN, CCM

One of the primary rules physicians and nurses learn in school is "if it is not documented, it is not done." Another concern expressed by medical professionals in our litigious society is "remember that you may need to defend what you charted in a court of law." Finally, attorneys caution healthcare professionals that the more they chart, the more they may have to defend.

Although these statements are not contradictory, healthcare professionals are typically cautious. However, with the implementation of RAC audits, documentation must be comprehensive because it helps ensure that hospitals receive fair and justifiable reimbursement.

Given the potential effects of a RAC audit, healthcare professionals must understand why they should carefully document the following:

Presenting symptoms
Rationale for a particular level of care
Treatments provided to improve a patient’s clinical status

Healthcare professionals must also substantiate their clinical judgment as to why a patient needs to remain in a given level of care on a daily basis. The case manager should confirm that the documentation is accurate and consistent with the hospital’s level-of-care criteria (e.g., Milliman, Interqual). If clinical documentation is not consistent with screening criteria, it must define the rationale for treatment decisions.

Check out the November 2009 issue of Case Management Monthly to read the other creative ways to reduce LOS. You can also discover the benefits of becoming a Case Management Monthly subscriber.

Regulations: CMS announces inpatient hospital deductible and more

Medicare Weekly Update — Tue, 27 Oct 2009 16:23:00 +0000

CMS publishes rates, deductibles for 2010

On October 22, CMS published in the Federal Register three notices to announce the inpatient hospital deductible, Part A premium, and Medicare Part B monthly actuarial rates, premium rate, and annual deductible for 2010.

View the notice regarding the inpatient hospital deductible for 2010.

View the notice regarding the CY 2010 Medicare Part B monthly actuarial rates, premium rate, and annual deductible.

View the notice regarding the Part A premium for 2010.

View a related fact sheet.

Note: CMS Announces the 2010 Medicare Premiums and Deductibles

Medicare Weekly Update — Tue, 27 Oct 2009 05:06:00 +0000

Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

CMS recently announced the CY2010 Medicare Part A deductible for inpatient hospital services. When a patient is admitted as an inpatient, the deductible will increase from $1,068 in 2009 to $1,100 in 2010. In addition, beneficiaries will pay an additional daily coinsurance of $275 for days 61 through 90 and $550 for lifetime reserve days. For 2009, the corresponding amounts are $267 and $534, respectively.

Click over to the MedicareMentor Blog to read more.

Transmittals and MLN Matters articles: CMS updates interest rate, clotting factor fee, and more

Medicare Weekly Update — Tue, 27 Oct 2009 05:00:00 +0000

CMS issues reasonable charge update

On October 23, CMS issued a transmittal to update the reasonable charge for splints, casts, dialysis supplies, dialysis equipment, and certain intraocular lenses.

Effective date: January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

CMS replaces previous instructions for coverage of IRF services

On October 23, CMS issued a transmittal in which it replaced previous manual sections that describe coverage of inpatient rehabilitation services provided in inpatient rehabilitation facilities (IRF). CMS made the changes pursuant to recent regulatory changes that can be found in 42 CFR 412.622 (74 FR 39762 (August 7, 2009)).

Effective date: For IRF discharges occurring on or after January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

CMS clarifies role in obtaining OCR clearance

On October 16, CMS issued a transmittal in which it made revisions to the State Operations Manual sections regarding ascertaining compliance with the Office for Civil Rights (OCR) requirements.

Effective date: October 16, 2009
Implementation date: October 16, 2009

View the transmittal.

CMS updates clotting factor furnishing fee

On October 16, CMS issued its annual update to the clotting factor furnishing fee.

Effective date: January 1, 2010
Implementation date: January 4, 2010

View the transmittal.

View a related MLN Matters article.

View a related Job Aid article.

CMS updates overpayment/underpayment interest rate

On October 15, CMS implemented the quarterly update to its interest rate for Medicare overpayments and underpayments. CMS instructed contractors to implement an interest rate of 10.875 percent effective October 22, 2009.

Effective date: October 22, 2009
Implementation date: October 22, 2009

View the transmittal.

CMS updates FDG PET transmittals

On October 16, CMS rescinded and replaced previous transmittals on its new coverage framework for FDG PET for solid tumors and myeloma. The effective date has been changed to April 3, 2009, and the implementation date has been changed to October 30, 2009. Some business requirements have been revised. All other information remains the same.

Effective date: April 30, 2009
Implementation date: October 30, 2009

View the transmittal to the NCD Manual.

View the transmittal to the Claims Processing Manual.

View a related MLN Matters article.

CMS updates 5010 transmittal

On October 16, CMS rescinded and replaced a previous transmittal that instructs the Medicare Administrative Contractors and the Shared System Maintainers to implement the changes in version 5010 of transaction 835 - Health Care Claim/Payment Advice and Updated Standard Paper Remit (SPR).

Effective date: January 1, 2010
Implementation Date: January 4, 2010 for A/B MACs, DME MACs, and FISS; January 4, 2010 and April 5, 2010 for VMS; July 5, 2010 for MCS

View the transmittal.

CMS reconsiders blanket non-coverage of MRI for blood flow determination

On October 16, CMS issued transmittals finding that the blanket non-coverage of MRI for blood flow determination at section 220.2 of the NCD Manual is no longer supported by the available evidence. Therefore, CMS is removing the phrase “blood flow measurement” from the NCD, giving local Medicare contractors discretion to cover (or not cover) this.

Effective date: September 28, 2009
Implementation date: January 4, 2010

View the transmittal to the Claims Processing manual.

View the transmittal to the NCD Manual.

View a related MLN Matters article.

Another Medicaid reduction possible when stimulus funds are gone

Patient Access Weekly Advisor — Wed, 21 Oct 2009 16:08:00 +0000

The decline in tax revenue and increase in Medicaid enrollment combined to put the squeeze on the Medicaid budget for many states.

As a result, 13 states will reduce Medicaid pay for physicians in fiscal year 2010. They include: Georgia, Louisiana, Minnesota, North Carolina, Vermont, Wyoming, California, Utah, Washington, Colorado, Hawaii, Maryland, and Ohio..

In fiscal year 2009, Medicaid enrollment grew by 5.4% and total program spending increased by 7.9%, the fastest pace in five years. Without the federal stimulus bill, the current economic climate would have forced states to cut Medicaid funding even more drastically. That additional federal funding for Medicaid runs out December 31, 2010. This has Medicaid directors worried about cuts that may be in store for fiscal year 2011.

Source: American Medical Association

CMW sneak peek: What are some creative ways to reduce LOS?

Case Management Weekly — Wed, 21 Oct 2009 05:00:00 +0000

by June Stark, RN, BSN, MEd

Strategic innovations for reducing length of stay (LOS) that have emerged in recent years provide a wide range of choices for case managers.

Many innovations have become predictors of success and may enhance hospital throughput from the ED door to discharge. These initiatives also cross the entire healthcare continuum, providing case managers with the opportunity to select initiatives that have a focused effect on LOS.

I’ve listed many of these initiatives in chronological order, from the beginning of the hospital-based continuum to the conclusion of the stay:

Institute preoperative admission screening for all elective surgeries to decrease LOS. Positioned on the front end, the case manager meets the patient and/or family and sets hospital expectations along with preadmission discharge planning.

At the time of admission, a unit-based case manager assignment model is more reliable for reducing LOS when compared to specialty case manager assignment. The advantage of unit-based case management is that the case manager is present to ensure completion of all discharges. Specialty-based case managers often follow a physician group’s patients from one unit to another. A case manager’s travel time can average approximately 90 minutes, according to published reports.

Productivity benchmarks

HIM Connection — Tue, 20 Oct 2009 19:23:00 +0000

With audit contractors scrutinizing coding accuracy and an upcoming transition to the ICD-10 coding system, coder productivity is more important than ever.

During an August 18 HCPro audio conference, “Benchmarking Coder Productivity to Improve Efficiency and Justify FTEs,” Rose T. Dunn, MBA, RHIA, CPA, FACHE, COO of First Class Solutions in Maryland Heights, MO, discussed the results of HCPro’s 2009 coder productivity benchmarking survey and provided tips on how to assess standards.

According to the results, respondents from inpatient facilities expected the following from their coders:

Inpatient records

12%: Fewer than three records
30%: Three records per hour
14%: 3.5 to 3.75 records per hour
10%: Four records per hour
6% Greater than four records per hour
29%: Not applicable

The American Health Information Management Association (AHIMA) and the Healthcare Financial Management Association (HFMA) released benchmarking data in 2007 and 2004, respectively. The respondents in those surveys had expectations similar to those of HCPro’s survey respondents. However, Dunn noted two areas that were vastly different from the survey data: the ED and ancillary.

The AHIMA data showed an expectation of 15 records per hour, whereas the HFMA data listed 24 per hour in the ED. For ancillary, AHIMA indicated 30 records per hour, whereas HFMA showed 55.

Note: For more results from this survey, visit the HCPro Web site.Subscribers to Briefings on Coding Compliance Strategies have access to this article in the October issue of the newsletter.

Note: Implementation of permanent and nationwide RAC Program

Medicare Weekly Update — Tue, 20 Oct 2009 05:00:00 +0000

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.

Now that CMS has implemented a permanent and nationwide Recovery Audit Contractor (RAC) Program, as authorized by the Tax Relief and Healthcare Act of 2006, hospitals need to keep themselves informed about the issues that have been approved for review in their region. Going forward, the four regional RACs will continue to review claims on a post-payment basis, using standard Medicare policies. They will be limited, however, to a three-year look-back period, with no review of claims paid prior to October 1, 2007.

Click over to the MedicareMentor Blog to read more.

Other Issuances: OIG audits Epogen, oxaliplatin, Region B RAC updates issues, and more

Medicare Weekly Update — Tue, 20 Oct 2009 05:00:00 +0000

CGI updates approved audit issues

CGI Federal, the RAC for Region B, has posted an updated list of approved audit issues.

View the updated list.

OIG audits Epogen payments

On October 8, the OIG issued two audit reports on payments for Epogen administration at University of Virginia Medical Center–Lynchburg Dialysis and Bon Secours Baltimore Hospital Renal Dialysis Center. The OIG found that the facilities did not meet Medicare payment requirements for some dates of service and that policies and procedures were not always followed.

View the OIG report on Epogen reimbursement to the University of Virginia Medical Center–Lynchburg Dialysis.

View the OIG report on Epogen reimbursement to the University of Bon Secours Baltimore Hospital Renal Dialysis Center.

OIG audits oxaliplatin payments

On October 7, the OIG issued an audit report of payments for oxaliplatin administration made during 2005 by National Government Services (NGS), a Medicare fiscal intermediary for West Virginia. The OIG determined that NGS made overpayments totaling $433,000 for oxaliplatin drug services.

View the OIG report.

CMS posts new RAC FAQ

Will Code N432 appear on the remittance advice for Recovery Audit Contractor (RAC) adjusted claims?

Read the answer.

Two new issues for RAC Region D

The RAC Report — Thu, 15 Oct 2009 05:00:00 +0000

HealthDataInsights (HDI) has announced two new issues for region D. HDI can now audit DME providers in all region D states for the following two issues:

Urological bundling
Wheelchair bundling

For more information on these issues, visit the HDI Web site.

As always, the latest RAC issues for each state are posted on the Revenue Cycle Institute ”Tools” Web page. Simply click the link at the top of the page to download a chart of RAC activity in your state.

CMS plans appeals town hall meeting

The RAC Report — Thu, 15 Oct 2009 05:00:00 +0000

CMS planned a town hall meeting for November 5 from 1-3:30 p.m. Eastern Time to discuss appeals of Medicare payment denials under Section 935 of the Medicare Modernization Act.

To pre-register for the conference call, e-mail medicareoverpayments@cms.hhs.gov. CMS will release more information about the meeting in the coming weeks.

CMS releases new, updated RAC FAQs

The RAC Report — Thu, 15 Oct 2009 05:00:00 +0000

CMS issued the following new RAC FAQ on its Web site September 30:

If I am a chain provider whose FI is WPS (serving as the national fiscal intermediary) who will my RAC be?

In addition, CMS updated the following question on September 25:

I heard that RAC medical record request limits will be based on my 2007 claims volume, then I heard on 2008. Which is it?

Click here to view CMS’ latest RAC FAQ.

Revenue Cycle Institute releases Observation white paper

The RAC Report — Thu, 15 Oct 2009 05:00:00 +0000

The Revenue Cycle Institute has released a new White Paper, “Inpatient or Outpatient Only: Why Observation Has Lost Its Status,” by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

To download the free white paper, visit the Revenue Cycle Institute Web site and click on "White Paper."