Let us take a look at some of the known RAC issues, things that you should be aware of, internal audit programs that you can start now. You can also start data mining your own claims. Go through this expert healthcare compliance article to know more.
You have your claims database. Start looking at it as if you were a RAC. Start looking at it as if you were RAC contractor. What would you look for? Then of course, if you do find weaknesses, if you do find areas where the RAC might question what you've done, you need to shore that up somehow.
And this is going to cost money. It's going to take up resources like personnel. And yes, it is going to cost money. And the really, the sad thing about all of this is we're just trying to keep money that we've already been paid. It's not as though we're going to get any extra money.
You need to study the RAC program as outlined by CMS rules. The CMS website has some pretty good material. They've reported on the demonstration project. You must understand that RAC audits are different. And they're different in the sense that they're going to come to everyone.
Many of the DOJ, OIG audits even the Medicare contractor audits, you may be at a healthcare provider like a hospital and you may have never seen a federal auditor in your life, okay, which is not bad, unusual. However, with the RAC audits, you will. Now, you may not see them but you are certainly going to be in contact with them.
Our expert mentioned this in a healthcare webinar that you need to identify potential issues, problems, what are they going to be looking at? In other words, you want to beat them to the punch if you can.
Objective reviews versus subjective reviews
Now, one of our big challenges here is objective reviews versus subjective reviews. In hospitals, what you're going to find and in skilled nursing facilities and physicians and clinics as well, what you're going to find is that they're going to attack medical necessity, medical necessity. That is going to be the overarching issue.
Now, the problem with medical necessity is that it is subjective and it's always easier to judge the medical necessity of something after the fact. It's a little harder to judge it upfront. So, one of the things you need to look at - and many of these issues are - they're not new.
Let's go to the emergency department. The OIG every year for the last 10 years has had the emergency department on their list in one form or another. And the issue is we're doing too many diagnostic tests in the emergency department. These things are not medically necessary as per healthcare rules.
Well, we may determine that it wasn't medically necessary but at the time the ER physician was trying to make a determination, the ER physician needed that information. But how are we going to fight this. This is subject everyone. So, stand by on that one.
This is the one that's going to be the trickiest. You should be doing internal audits or have external consultants doing audits to see if you do have any potential problems, organizational structure, how are we going to do the appeals if we are going to do appeals, et cetera, policies and procedures surrounding the appeals process, what issues will we take all of the way or how far will we take them, et cetera.
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