Healthcare Training: Learn How to Deal with RACs


The RACs are coming. Whether you're ready or not, they're coming. Read this expert RAC training article and learn more how to deal with an RAC contractor.

How do you interact with the contractors?

Well, don't worry. They'll contact you. And you also can contact them directly. And so, overtime you'll want to set up lines of communication. Whether you really want to or not, you're going to need to set up lines of communication and you might as well do it in positive way. They're there. They're going to be there. Accept it and do your very best with what you have to work with period.

What about operational impacts? Our expert mentioned it in a healthcare webinar that this one we're probably underestimating the operational impact because there's going to be a lot of activity. In other words, they're going to be sending notices of overpayment. We're going to have to look at those overpayments. Are they correct? Incorrect? Do we have additional documentation, whatever the case?

Mar 31, 2019
Kelly Dennis

They're going to requesting records when they conduct a healthcare audit. In other words, there is going to be some time and trouble on the part of hospital personnel to respond to requests, to respond to demands of recoupment, to respond to medical record copy request, et cetera.

But then, if you get into situations where you are appealing possibly hundreds, if not thousands of cases, then you're going to have to track all of that stuff. You're going to have to develop supporting documentation, you're going to have to create statements, clear, concise, convincing statements as to why there was not an overpayment, okay? So just everyone, keep in mind please there is going to be a very significant operational impact.

Will they collect monies in a lump sum?

There are different ways in which they collect money. Normally it's recoupment by withholding current payments to pay for the overpayment demands as per the healthcare guidelines.

What issues will they be looking at?

They're going to looking at literally everything period – correct healthcare coding, medical necessity, sufficiency of documentation, the list goes on and on. Probably the most troublesome is medical necessity and then right behind that, sufficiency of documentation. Those are both subjective.

And yeah, we can look at a case and say, “Oh, I don't think it's medically necessary.” “Well, we thought it was at the time. The doctor ordered it. It looked good. We did it.” But after the fact, sometimes it's easy to look at things and say, “Well, that wasn't really medically necessary.” Or we can always look at documentation and say, “Well, it's there but it doesn't look complete to me. It doesn't seem as though it really supports the medical coding and the payment.”

Can they look at all issues? Well, the answer is, “No.” There are some delimitations. CMS does have to give them permission on what they can look at. But we all realize pretty clearly that even though their scope may not be unlimited, it's not going to be highly delimited either.

Next, what is this so-called extrapolation process? Well, the extrapolation process - and we'll have some examples later under the notes. The extrapolation process is where they do a limited sampling, do the healthcare audit on the limited sampling and then extend the results of that limited sampling audit to a much larger universe.

You might have a universe of 2,000 cases, they'll come in and look at 300 cases out of the 2,000, determine the error rate on those 300 cases and then extend or extrapolate that result to the entire population. Now, first of all, we don't even know for sure they're going to do this, but they are allowed to do it. And we would suggest that if they're allowed to do it, they will end up eventually doing it.

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