Updated on: June 22, 2012

RAC Delay Can Mean Denial

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Original story posted on: June 3, 2009

cengle120xBy Carla Engle, MBA


You all may have heard the adage "delay doesn't mean denial," which is true in many life circumstances. Unfortunately, in the world of RACs, delay can mean denial: denials of claims that translate to cash lost.


Now, while you may be breathing a sigh of relief, this is not a time to sit back and delay implementing your RAC plan until next year.

Remember, we've had a breather before, during the work halt tied to the contractor protest, and unfortunately, many facilities didn't view that as additional prep time then.

 

So what does this new respite mean for you and your facility's preparation for the RACs?  USE THIS TIME to continue (or start!) forming your RAC plan:


Prepare for the automated reviews


The automated reviews still are happening very soon. Have your plans in place to start handling those reviews as the determinations start coming in, and know your facility's policy on how you're going handle any appeal opportunities.


Prepare your RAC team and processes for the complex reviews


Have your team's roles and assignments established, and start conducting mock RAC audits to firm up the workflow within your facility. Be ready not only on the front end, for handling the medical record requests, but also on the back end, for determining whether you are going to pursue an appeal and, if so, how you will handle it.


Identify your possible areas of vulnerability by using data mining


Take your own three-year data sample and run the targeted areas from the demonstration project. Do your own internal audits of them to be aware of possible risks before the surge of medical record reviews by the RACs ensue.


Use a tracking database not only for RAC audits, but for other auditing bodies as well


If you don't have tracking software, get it quickly. Getting used to your software and programming your own internal workflow into it helps you prepare both for the RACs and other auditing bodies that are likely to be right behind them (MICs, ZPICs, QIOs).


Remember, 2010 is just around the corner, and if you aren't already in the throes of your RAC committee processes, start them now. Bear in mind that the time period for RAC expansion review remains from Oct. 1, 2007 to the CURRENT date, so any additional delays can add several months to the review period and increase your number of claims subject to review, making your RAC requests more difficult to handle in a timely manner.


Many facilities that were overwhelmed by their workloads during the demonstration project lost claims on technical denials, in which denial was automatic and any appeal rights were lost.  Don't let this happen to you by failing to plan ahead.


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About the Author


Carla Engle, MBA, Product Manager


Carla's background includes more than 20 years in hospital and physician practice operations, particularly in reimbursement and billing functions. Prior to joining Wolters Kluwer recently, she was the vice president of compliance for a national revenue cycle solutions company, and prior to that, was in the Reimbursement Training Department with HCA. For several years she also headed up the Part A Fraud Investigation Unit for a CMS Program Safeguard Contractor (PSC) where she was successful in the prosecution of several national cases. In her revenue cycle compliance capacity, she worked with a number of clients in California and Florida with Recovery Audit Contractors (RACs) in setting up processes and appeals.

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