RAC Training: Policies and Procedures RACs are Going to Use

Keep in mind that you need to be looking at and perhaps even conversing with your RAC as to what policies and procedures they are going to use. Read these expert tips and strategies provided by our speaker in a health system conference.

Now, under the Medicare program, we have some gaps in guidance. That's an understatement.. And sometimes even though we very specifically ask Medicare for guidance, they don't really give it to us. So, we have these gaps.

Now, the question is, are we going to be held accountable for these gaps or not? And generally the answer is going to be yes. But the RAC contractor conducting an audit is going to look at national coverage decisions, all of the manuals, local coverage decisions. He will probably use any and everything they can lay their hands on period.

But again, in order to audit - you have to have metrics. You have to have standards. Otherwise, you can't judge whether something is correct or incorrect unless you have a standard.


And in some cases, the standards are going to be sort of, well, a little ambiguous, everyone. That's probably the best way to put it. So as you prepare for the RACs, keep this ambiguity in mind.

When you look at cases - let's take that short term inpatient admissions, if you look at those cases, expand your thinking and ask yourself, if a RAC look at this case, would they claim that it's an overpayment? And in many cases, you're going to judge that it is even though technically in your medical judgment, it isn't, which you may have to expand your thinking a little bit.

CMS will be coordinating RAC audits relative to other investigations. In theory, they're looking for underpayments as well as overpayments but don't hold your breath. And they're paid on a contingency basis. So, if they don't find overpayments, they're not going to get anything, all right? So you can almost be guaranteed they will find overpayments.

Automated reviews: This is where oftentimes those data mining. They'll start looking at your medical billing claims for unusual combinations, occurrences, sequences. And yes, they'll find some stuff.

And yes, as an auditor found this also, where we have double surgical coding because there's a surgical code coming from the chargemaster and there's also a surgical code coming from health information management coding personnel.

Yes, so we have double surgical medical coding. Yes, these kinds of things happen. And yeah, they're going to find them. If they find that we reported the surgical code twice which is a single surgery, then yeah, there was an overpayment.

Complex reviews is where the RAC contractor actually going to look at the medical record. Now, you know if we look at the hospital side particularly, some of these medical records can become huge. Again, the question is going to be, well, what exactly are they looking for? How are we going to get this information to them?

And if they do come back and say, “No, this should not have been an inpatient admission”, how are we going to defend ourselves? Let's face it, if you're a hospital and the doctor comes to you and says, “Admit this patient to the hospital” you're probably going to do it.

Now, hopefully, utilization review will get there before they're discharged. And maybe we can use condition code 44 to get it converted over to an outpatient observation. But sometimes that doesn't happen. That doesn't happen.

Handling of underpayment situations

Now, that would really be nice if they find a bunch of underpayments for you but those are then referred back to the fiscal intermediary or the carriers as the case may be. And then they're supposed to do something. And we'll have to wait and see how that's actually going to work.

Settling and/or compromising relative to overpayments

In other words, you may agree automated reviews. They said, “Yeah, you did two 36430s on the same day therefore, you should only have been paid one.” You may disagree but you may simply say, “Okay. We'll simply repay that second code.”

Obviously if you don't respond to medical record request then we have a problem. And if there are any delays, we can get into interest on overpayments, underpayments, that's part of the appeal process as per CMS rules.

And you may want to take some of these things up by appeals letter. Now, everyone, this is part of your preparation because you do need to be thinking about well, what kind of cases do we want to take up the appeals letter?

RAC Training Tip: Now, the first couple of steps in the appeals process are not that bad. You're going to have to develop some documentation. You're going to have to write some position papers to defend your position. But the time and trouble of all this is not that great.

But when you go beyond, you know, and get up step three and four, then all of a sudden, you know, you get up to your administrative law judge area and you're going to have to have consultants, legal counsel, et cetera. So you need to be thinking about that as you prepare.

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