Updated on: June 22, 2012

Pressing RAC Issues Get Ironed Out

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Original story posted on: February 17, 2010

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By Chuck Buck and Dennis Jones

Contributing editor Dennis Jones certainly felt as if he was on the other end of the query process when providers were querying him during Monitor Monday's podcast earlier this week.


During the live half-hour podcast, a number of pondering providers were querying Jones on the query issue.  Jones, Director of Compliance Services for CBIZ KA Consulting, answered as many as time would permit. Typical of the questions and his responses are the following:


HDI is requesting both the UB and the physician queries - Terri


"The fact that HDI is now asking for a copy of the UB and the Physician Query (response?) is interesting. I think it's prudent to supply the response to a physician query if they ask for it or not.    Anything that supports your DRG assignment or level of service is a good thing. Regarding HDI's requirement that hospitals include the UB form along with the clinical records, the South Carolina Hospital Association addressed that issue successfully with Connolly Consulting.  The SCHA made the point that the hard copy UB may not be the same as the information that processed based on the CMS RTP process for claim corrections in FISS. Connolly agreed and has now removed this request from their list of required documentation.


If your RAC is requesting a copy of the UB, I would suggest this issue be addressed with the CMS liaison for HDI, Brian Elza."


Today there was discussion about the appropriateness of submitting the UB to the RAC.   The UB is one of the requested items on the CGI form letters.  It is implied to be one of the components of the "entire medical record." I'm unclear as to what potential harm providing CGI with the UB on these requesting records can mean to my facility?   If it saves administrative time by not supplying, is that the only reason and is that enough of a reason to push the issue?   Or is there some other reason to not supply the UB.
Per our HIM people the request to supply the ICD9 codes as part of the medical chart seems to fall within this same category as the UB - Scot


Scot,


"If your RAC is requesting a copy of the UB, I would suggest that this issue be addressed with the CMS liaison for CGI, Scott Wakefield."


Physician Queries was on the last request for documentation from Connolly and the UB was removed -- Nancy


Hi Nancy,


"When Connolly requests records, they ask for "the following applicable components of the medical record and/or other documentation to support payment of these claims."  The four RACs are not obligated to conduct their audits in an identical fashion, but Connolly Consulting, during a Q&A after an Outreach Education session stated that providers should "send any documentation necessary to substantiate (your) position...include as much information as needed ... prior to the denial."   This might include the response to a physician query, Physician Advisor evaluations, Care Management documentation, ambulance documentation, previous stay documentation, etc. If Connolly ever requests a copy of the UB, I would suggest that this issue be addressed with the CMS liaison for Connolly Consulting, Ebony Brandon."


As RAC activity steams ahead, now is a good time to incorporate some of this advice into your RAC strategic planning.  Here's what Jones suggests:


First, introduce the concept that RACs will request "clinical documentation" for which "medical records" is only a part.


Second, identify all sources of clinical documentation that can support your DRG or inpatient status assignment.


Third, through RACMonitor and other sources, stay aware of developments in other RAC regions and other states in your own region.


"And last, don't be afraid to be a squeaky wheel when it comes to problems and inconsistencies within the RAC program," advises Jones.  "Reach out aggressively to your CMS liaison and your Regional RAC contacts."


As stated above, the four RACs are not required to conduct their audits in exactly the same way.  However, general guidance from CMS does lend some consistency to the clinical documentation requests and the discussion and appeal process.


"Follow these recommendations and your hospital won't be taken to the cleaners," admonishes Jones.


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About Dennis Jones


Dennis Jones is the director compliance services for CBIZ KA Consulting. While Dennis is recognized as a leading RAC issues expert, his expertise covers a wide variety of topics including Managed Care, Uncompensated Care, Medicare and Medicaid Compliance, HIPAA, and Process Improvement. As such he has spoken previously at NJHA, World Research Group, and various state chapters of HFMA, AAHAM, and AHIMA. Dennis is a past-president of the New Jersey Chapter of AAHAM and has held senior management positions in provider, IT vendor and reimbursement consultant arenas.


Contact Dennis Jones

drjones@CBIZ.com
Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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