Most have not been very effective. As the reviews get closer, now is the time to take a more formal approach to establishing this elusive number. Based on our experiences, a good approach to "dollarizing" your RAC risk should have the following components:
- Establish vulnerabilities: make a solid estimation of the number of at-risk cases for your facility based on known RAC targets
- Ask yourself: how do you stack up when it comes to your facility's performance? Do the cases meet criteria, and will they "pass" RAC review?
- Determine your ability to "harden": for those cases that initially do not meet criteria, do you have the resources to "harden" those records?
- Using these guidelines, establish a range of sensitivity upon which to base your dollar amount
Employing these methods can help put you on the right path to establishing a realistic, fact-based financial estimate.
The first step in understanding your financial exposure to the RAC review process is to establish what services, DRGs and cases are at risk for being targeted. Without this important step, any financial analysis amounts to nothing more than a "shot in the dark." Understanding specific areas of vulnerability enables you to remedy them and begin to better identify and assess risk areas.
How Do You Stack up?
The next step is to evaluate how your areas of vulnerability actually hold up under the scrutiny of review. Even though your facility may have a significant number of problem areas, this does not necessarily indicate that all of the cases identified will require a payback. The only way to determine where your facility truly has a financial vulnerability is to thoroughly review each identified case to establish a level of exposure.
Ability to "Harden"
Once you have established specific problem areas and have a good idea of the number of cases for which your facility may be financially vulnerable, the next question to ask is "How many of those cases can be "hardened?" A review may indicate that a large number of cases, as they currently are presented, do not meet criteria. The process of "hardening" a record enables a facility to collect and present existing documentation in support of the case to demonstrate to an outside reviewer why a course of action was taken for a patient. Often times, some information that would support such actions is not readily available in the patient's record, were never included in the record, or are not an official part of the record -- but the information does exist. The goal in this step of the process is to determine how many of the cases that do not meet criteria can be strengthened to hold up under review.
Establishing a "Range of Risk"
In our experiences with many facilities nationally that have undergone this process, we easily can establish a range of risk once a review of data has been conducted.
Based upon identification of cases in each area of vulnerability (i.e. inpatient coding, medical necessity, outpatient services), the level of estimated risk and range of risk (established specific risk levels for each area, established range of risk for each area), and an overall reimbursement amount, dollar ranges can be assigned.
Assume that a facility has 149 out of 987 cases, or 15.1 percent, in a certain sample that trigger a risk variable. Within this sample, there is a low and high range of risk. Based upon our experience and the facility's mix of cases in each area of vulnerability, on the low risk range, 28 cases (2.8%) likely would fail audit, while on the high risk range 65 (6.6%) cases likely would fail. Annualized, this translates into a low range risk of 165 cases and a high range risk of 388 cases.
Low Range Risk High Range Risk
Sample 987 987
Risk 149 149
Likely to fail 28 65
Percentage fail 2.8% 6.6%
Annualized 165 388
Estimated Reimb. $5,640 $5,640
Risk $ 930,673 $2,188,491
This range of risk can be stratified further by applying the findings of your "hardening" review. If the facility has good documentation and average organization, assume that "hardening" would work in 80 percent of the cases. If its documentation is average and its organization is not any better, assume "hardening" will work in 60 percent of the cases. If its organization is good, but its documentation is poor, assume "hardening" will work in 20 percent of the cases. If you feel that "hardening" will not help in most cases, assume no adjustment.
Hardening Low Range Risk High Range Risk
Risk $ 930,673 $2,188,491
80% Improve $ 186,135 $ 437,698
60% Improve $ 372,269 $ 875,396
20% Improve $ 744,538 $1,750,793
No Improve $ 930,673 $2,188,491
For this facility, the range of exposure varies greatly based on how well-prepared it is for RAC review, existing volume in the targeted RAC areas, and how well it fares when cases are reviewed. The financial exposure without any record "hardening" can vary from $900,000 to $2.1 million. When such adjustments are factored in, the exposure can range from as little as $186,000 to as much as $1.7 million.
The reality of RAC financial exposure lurks in the details. A detailed analysis presents realistic tangible ranges upon which the C-Suite can base a financial exposure. Without this level of analysis, a guesstimated financial impact remains just a shot in the dark.
About the Authors
Samuel A. Donio, Jr., MBA, is the President of CBIZ KA Consulting Services, LLC. An authority on sound and compliant healthcare financial management, Mr. Donio has developed numerous products and services to meet the ever-changing needs of healthcare providers.
George L. Kelley is the Chief Operating Officer for CBIZ KA Consulting Services, LLC. He is a nationally recognized speaker noted for his expertise in discussing the many topics that impact healthcare financial professionals including the Medicare outpatient prospective payment system, Recovery Audit Contractor (RAC) Preparation and HIPPA Readiness. Additionally, he assists clients in increasing net revenues by recovering managed care underpayments and recalibrating charging structures to ensure his clients receive the highest level of reimbursement.