Provider Consulting Solutions

Description

By establishing strong internal controls, hospitals can use these findings to train coders, physicians, medical record staff and others to help minimize future improper payments. - CMS in the 2008 RAC Demonstration Report- RAC Preparedness Education PCS will work with the Hospital to develop the most efficient approach needed to cover the RAC-related education of the Hospitals management, medical staff and others. The initial focus of the RAC preparedness education will include the following: RAC Team Development and Support During the RAC demonstration, over 7% of recoveries involved the failure by providers to provide adequate documentation in response to a medical record request. These findings demonstrate clearly that managing RAC audit activities can be very challenging. PCS can help with all phases of RAC team development and support, including: RAC Risk Assessment To respond effectively to RAC, providers need to understand the nature and magnitude of their RAC risk. The cornerstone of PCS assessment is an analysis of the Hospitals inpatient and outpatient claims for appropriate payment. Our focus is on both overpayments (risk) and underpayments (opportunity). The claims analysis includes both known RAC targets, as well as potential future targets. PCS utilizes our proprietary screening software, Sentinel, to analyze claims data, identify potential risk and opportunity areas, and quantify financial exposure. Assistance with RAC Appeals - Although 34% of appeals filed during the demonstration were successful, only 22% of denied claims were appealed. Many providers in demonstration states reported they did not have the time or expertise to pursue appeals. Not every denial should be appealed, but when an appeal is warranted, every effort should be made to file well researched and documented appeals. The success of RAC appeals is determined by a variety of factors, including the quality and availability of supporting documentation, merits of the denial (i.e., the strength of the RACs rationale), and mitigating circumstances, such as age of the claim and specific clinical factors. Through our experience assisting New York client hospitals with RAC appeals during the demonstration project, we learned the critical importance of deciding which claims were worth appealing, and providing well-researched regulatory and claim-specific analysis to support the hospitals positions. Implementing RAC Lessons RACs will identify areas where hospitals submit inaccurate or inappropriate claims. Denials are often the result of an ineffective process or deficiency with documentation, utilization review/case management or coding. PCS operational experts can assist hospitals to develop and implement action plans to correct deficiencies and avoid future denials. After a successful demonstration project which started in New York, California and Florida, Medicare's Recovery Audit Contractor program is now being implemented on a nationwide roll out schedule .

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