By: Ernie De Los Santos

There is a common fear among rural providers that communities will wind up losing their local hospitals because CMS will bankrupt them, not based upon fraud and abuse, but rather based upon what the physicians do or do not put into their documentation, which the facilities have no way to control.

Many believe this to be completely unfair, and some are quite mad about it.

I came to Miami this week to attend the National Rural Health Association's (NRHA) 32nd Annual Rural Health Conference. The conference included speakers for various topics, including a keynote speech by former Speaker of the House, Newt Gingrich. At this conference, like my previously reported visit to the (TORCH) Annual Conference in Dallas last month, there was not a single session devoted to the RAC program or how to defend against it.

CMS had a single table set up at the conference's exhibitor area, with a single person there to man the table. There were no handouts about the RAC program, and while the nice young woman manning the table was familiar with the program's existence, she knew little about it.

Nothing for Rurals

I spoke to several people from other federal agencies, such as the USDA and HRSA, and while most were familiar with the RAC program, they, too, had little information about it. All of them, however, seemed to have a common impression about what the program will do to rural health providers in general: nothing good. Perhaps the most poignant comment actually came from an HHS official, when I asked if there was anything being done to help Rural and Critical Access Hospitals (CAHs) to survive RAC audits, which could quickly devastate a small facility. The official told me plainly, "CMS is not doing anything for the rurals."

At his keynote address, Mr. Gingrich made a big point of suggesting that the rurals need to go to Washington with, not simply their concerns, but with solutions. He suggested that lawmakers hear so many problems that they have little time to come up with the many solutions that are dearly needed. So, it behooves the constituents to come up with solutions, and to propose them to the powers that be.

I spoke to other people about this idea later, but few were hopeful. They felt that CMS seems to side most often with physicians, not facilities. Many were of the opinion that the American Medical Association, representing physicians, is far more influential in Washington than the American Hospital Association, representing facilities. This also came up in other conversations when I mentioned the fact that all associated physician claims could be denied if an inpatient claim is denied for a lack of documentation of medical necessity. It was pointed out to me that the key word in that statement is "could."

A RAC can choose to deny all associated claims in such a case, but this does not happen automatically. So, the physicians might be at risk, but they might not. One person recently heard a RAC representative speak about this at one of the CMS Provider Outreach Sessions. When asked directly if physicians would be held responsible for the poor documentation, not just the facilities, the RAC representative would only say that that might happen. Of course, that was not a very reassuring answer.

Some attendees I spoke to seemed more interested in discussing the "fairness issue" or the whole raison d'être of the RAC program. One State Rural Health Office director put it this way: "Is it fair that CMS should now, after the fact - after letting this go on for so long - be going back and penalizing hospitals for behavior that has for years been accepted and tolerated?"

We discussed this for quite some time, and it became clear that the fear he was expressing was more about the fear that communities will wind up losing their local hospitals because CMS will bankrupt them, not based upon fraud and abuse, but rather based upon what the physicians do or do not put into their documentation, which the facilities have no way to control.

As I've found at other conferences I've attended recently, there seems to be a pervasive hope that the RACs will be going after the "big guys" first. Unfortunately, as I've also said before, this will not necessarily be the case. RACs will not select providers to audit based upon their respective "size." In fact, they don't even know who a provider is until after they have decided to audit them.