The RACs Are Coming continues by Brianna Rogers

At Aurora Sheboygan Memorial Medical Center (ASMMC), we began the following RAC preparation phase by carrying out the following steps:  

1. Organize a multi-disciplinary facility RAC Readiness Committee representing the following areas; Health Information Management, Case Management, Quality Management, Administration, Finance, Medical Audit, and Billing.  This Committee was considered a sub-committee of the Aurora RAC System-wide Coordinating Council meetings.  The charge of this sub-committee was to determine representatives for each key functional area to focus on target areas, develop RAC policies and procedures, assess our facility risk, and educate top leaders on any potential financial impacts. Our first main objective was to develop an action plan outlining how we would prepare for the RACs, which included:
1. Determining a RAC Committee Chair for our facility that would organize and run the RAC Committee meetings, represent our facility at the Aurora System-wide Coordinating Council, and whom would develop the action plan which showed delegation of various tasks to committee members.   The ASMMC RAC Chair would report to the designated Aurora System-wide RAC Coordinator on any issues that may arise at our facility.

2. Assigning a Health Information Management RAC Coding Lead for our facility that would ensure that the Coding area was reviewing key RAC target areas.  Due to staffing and resource limitations at our facility, we contracted with an outside vendor to assist us with the review of the quality of our coding.  Following the release of the Demonstration Program results, we decided to send a sample of the following types of charts for quality review, among other cases as determined by our Medicare data:

q  DRG’s with Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs) with only one secondary diagnosis

q  Signs and Symptoms DRG’s

q  Excisional debridements

The Coding Lead would be responsible for reporting the coding quality review results at each site RAC Committee meeting, as well as any potential documentation improvement suggestions.  

3. Assigning a Case Management RAC Lead for our facility that would conduct internal self-assessments to make sure submitted claims met Medicare coverage rules. The RAC Demonstration Program showed some patterns of errors in the following areas:

q  Admission level of care

q  Readmissions within 24 hours

q  Discharge status codes

q  Specific DRG’s

The Case Management Lead is responsible for identifying any medical necessity target areas, providing education and scheduling any action planning activities in patient status determinations.  The Case Management Lead would be responsible for reporting any medical necessity findings and proposed action steps at the each site RAC Committee meeting.   

4. Assigning a RAC physician Champion for our facility that would be our voice to all facility providers. Our physician liaison will provide education, instruction, and training to physicians about their role in consistently demonstrating medical necessity through appropriate medical record documentation.  We have discussed the need for all providers to be informed and re-educated on the admission process, as well as how to document all procedures and exams appropriately.

5. Develop policies and procedures to respond to RAC requests for medical records, denials and appeals.  Key representatives from the ASMMC RAC Committee developed site-based procedures to follow in response to communications received by the RACs.  These policies and procedures will then be presented to the RAC Coordinating Council.  All RAC Communications will go to a central location within Aurora to the System-wide RAC Coordinator where they will be tracked and distributed. 

6. Organizing a presentation for our site Administration and Finance leaders, in conjunction with our contracted vendor that includes the results of a thorough external review of our coding, documentation, and medical necessity of past and present discharges. The results presented predict the potential financial impact of the RAC audits; reveal any areas where documentation or coding education is needed, and identify medical necessity and patient status issues that need to be addressed at our site.

At ASMMC, we will continue to focus on our action plan and target areas.  We find it beneficial to reference the newest publications and any other resources that we can find relating to the RAC audits.  Some examples are listed below:

 www.ahima.org

The following article is useful in beginning the preparation phase. Johnson, Kathy M.; Bloom, Allison; Morris, Denise; Madamba, Rod. "RAC Ready: How to Prepare for the Recovery Audit Contractor Program" Journal of AHIMA 80, no.2 (February 2009): 28-31.  AHIMA also offers many audio-seminars and products to assist in preparing for the RACs.

q  www.wha.org

The Wisconsin Hospital Association (WHA) website is a helpful tool in  researching where to start in preparing for the RAC audits.  This website also has links to the Medicare RAC Region B website as well as the American Hospital Association (AHA) website.  

Providers ought to check their RAC’s websites often to see the latest approved areas for review in anticipation of potential vulnerabilities to the reviews and denials. Providers should begin preparations for the RAC audits as soon as possible.  Valuable time and resources may be saved if a facility is in the position to respond to the RAC’s request in an efficient manner and if any improper billing practices are identified and corrected prior to the audit.  Any proactive measures that can be taken now may reduce operational strain that such an audit can place on a facility.