This is not the time to assume you know, or hope someone else does. So let's get clear about whom the "opponents" are, and what we all need to do throughout our respective organizations to deal with them going forward.
The descriptions of each RAC company have been taken from their Web sites. Please read the information to find out about their missions, talents, and expertise and to meet your "opponent."
Region A: Diversified Collection Services, Inc. of Livermore, Calif.
35 years of experience
"Diversified Collection Services, Inc. provides debt recovery services on behalf of state and federal government agencies and commercial financiers. It also provides hosted services, such as on-demand debt-management software solutions. The company was founded in 1976 and is headquartered in Livermore, California. As of 2003, Diversified Collection Services, Inc. operates as a subsidiary of Performant Financial Corporation. Performant Financial Corporation provides advisory services and technology solutions to healthcare, education, and collections industries. The company offers debt recovery and management, audit, and loan consolidation services."
Region B: CGI Technologies and Solutions, Inc. of Fairfax, VA.
35 years of experience
"Founded in 1976, CGI has evolved into a leading IT and business process services provider. Our more than 30 years of continuous growth is a testament to the confidence our clients place in us and to the commitment of our members. CGI offers its end-to-end services to a selected set of economic sectors where we have deep business and technical expertise. This allows us to fully understand our clients' realities and to have the know-how and solutions needed to advance their business goals. Our targeted industries include: Government and healthcare-helping organizations improve the performance of mission-critical functions through the innovative use of information technology."
Region C: Connolly Associates of Wilton, Conn.
30 years of experience
"Establishing itself in 1979 as a recovery audit pioneer, Connolly Healthcare introduced medical claim data mining audits to the healthcare industry in 1998, and is now recognized by commercial and government health plans as the recovery audit expert."
"The Recovery Audit Experts
Every step of a Connolly Healthcare audit is managed by professionals who have relevant healthcare experience and is supported by powerful and flexible technologies. Recovery findings are followed by root cause analysis and actionable recommendations to improve claim payment processes. And it's all done with an acute awareness of the client's day-to-day operations and a high sensitivity to their provider relationships.
Connolly Healthcare ... employ auditors with past recovery audit experience combined with rich and varied experience from all corners of healthcare. Recovery auditing is embraced by leading healthcare companies as a financial best practice for reducing overpayments, improving processes, and enhancing performance. Even if an average of 99.5% of all transactions and payments are processed correctly, the small amount of error can quickly add up to a large amount of recoveries."
Region D: HealthDataInsights, Inc. of Las Vegas, Nev. with more than 10 years of experience
"Applying its sophisticated technology platform developed over the course of more than a decade, HealthDataInsights works with healthcare payors to ensure that providers have been reimbursed accurately for care provided. HDI is engaged by public and private healthcare payors, as well as third party administrators and self-insured corporations, to analyze 100% of paid medical claims and to identify and recover overpayments resulting from error as well as fraud or abuse ("Claims Integrity Services"). This year, HealthDataInsights will audit and review over $75 billion in medical claims. The US Department of Health and Human Services has estimated that gross overpayments under the Medicare fee-for-service program were $20.8 billion in 2004, representing 10.7% of the total amount paid out under this federal program. "The healthcare industry has lagged behind many other sectors of the US economy in providing for efficient and accurate payment for products and services."
Who Are Your Experts?
So let's put all the above in context, shall we? These companies are experts in payer data mining, information system claim analysis and financial recovery of previously paid healthcare dollars - your dollars, which you already have been paid, booked and moved on. Who are your "experts" in information system software, claims payment, tracking and denials? Are they true experts, or rather the default assignee you HOPE can manage?
Now is not the time for assuming you're ok or hoping for the best; you must take the initiative and improve and integrate your information systems. Yes, it will cost money, but you can either pay now or pay more dearly later!
You must train enthusiastic existing staff or hire new staff. Rather than pile the responsibility on top of already overextended coders, business office employees, or patient access case managers who may or may not know the ins or outs of the work.
Please don't underestimate the power of a motivated staff member, but don't imagine that motivation alone necessarily will result in success against focused, experienced RAC staff paid to do what they know and enjoy and are likely paid better than your staff to boot.
Take advantage of every available opportunity to assess, review, educate, and improve the processes utilized by the necessary members of your organization, hospital, clinic, or practice.
Each of us will deal with these opponents. But who is on your team, who is a weak link, who gets it, who does not? What are your information system strengths or weakness, and when can they be upgraded? How will you win, place or show against these very talented, successful, motivated entities and their staff? Do you have the tools to win - does it matter? Absolutely.
Patients are counting on you and your organization to "know your opponent!"
About the Author
Patricia Dear has more than 30 years of experience in the healthcare industry, working within corporate healthcare entities, for-profit and non-profit hospital systems, legal defense and plaintiff counsel. She is a recognized national speaker on reimbursement and compliance. She is the president and CEO of eduTrax®.