June 24, 2009

RAC Implementation Creating a Healthcare Vortex

By

pdear120dsBy: Patricia Dear

 

A ‘vortex,' as defined by Webster's, is a "fluid flow involving rotation...(a) whirlpool; a situation regarded as drawing into its center all that surrounds it."

 

Since the RAC demonstration (2005-08) proved wildly successful in identifying and recovering Medicare dollars, the national program's announced implementation has created a virtual vortex in the healthcare industry.

 

Some hospital providers, physicians and other provider types are more than sick of hearing about the impending RAC program; they are ready to act and just want to "get on with it." Others, however, have no idea what the program means to them and the likely impact they will experience. How is that possible, to have such a difference in knowledge of and readiness for such a significant event regarding service providers' Medicare fees?

 

I recently spoke to a group of very talented and bright physicians, all committed to their community, their hospital and the respective survival of their own practices. More than three-quarters of the audience of greater than 100 had never heard of the RAC, did not know what a MAC was and in fact were not sure about why their hospital's CEO insisted they attend the evening meeting featuring the topic. When I asked how many (if any) of them thought they were reimbursed by Medicare adequately, not one indicated that sentiment - rather all felt that they were not reimbursed sufficiently, it was "too difficult and time consuming" to get paid, and if an alternative to Medicare reimbursement could be found they would (gladly) seek it!

 

Here's another interesting situation: in the same group, when their practice managers and the hospital personnel were asked "Who is your best payer?" the answer was "Medicare:" hands down, they said, they pay "best." Perhaps this is more of an indictment of other payers, but it's still a curious situation. Why the disconnect?

 

The Vortex

 

I never have experienced a tornado, but I can imagine, however, the terror of seeing a huge wind vortex with an apparent "mind of its own" swooping down where it happens to land, hopping over some homes and destroying others completely. Debris of all kinds is thrown about. Some homes survive, some don't, and then it moves on before it is completely gone. This is just what I imagine when I travel to facilities and practices, look at the faces in the crowd and listen to the concerns of many in healthcare today.

 

I hear a lot of the same questions from providers. When do we start getting demand letters? What impact will RACs really have? How long will the RACs be around? They're going to hit the "big guys" first, right? Surely they won't come after little ol' me, right?

 

Since the advent of the permanent RAC program, quite a cottage industry of professionals, consultants, and IT companies has arisen, all with their own spin on how to help the provider. The din of information has caused some providers to become selectively deaf or blind (perhaps they view this as just another Y2K scare), others to become ambivalent ("hey, it won't be that bad"), others to overspend trying to "buy the answer," and still others to get downright livid!

 

Let's get serious, though, since this IS serious. Is this rocket science or not? Why does this seem so complicated? What is the root of the problem?

 

Actually, you probably know the answers:

 

  • No, it's not rocket science, but it is medicine, which does seem to involve more than just science.
  • It appears complicated because it IS, since it involves individuals, who are not machines and are actually quite complex.
  • And the root of the problem is... wait for it... you guessed it... DOCUMENTATION.

 

Why documentation? Because contracts are involved. You, the provider, have a contract with a (so-called) payer to provide very specific services under very specific circumstances. Ever notice that RAC denials have nothing to do with actual care provided? Ever had a payer denial for not providing enough service to a patient?

 

Remember this one statistic I have quoted often, taken from the report on the pilot program that launched the RACs:

 

About 83% of RAC denials were for preventable coding or documentation errors.

 

Electronic medical record companies are attempting to provide solutions and filling your mailbox with offers. Documentation specialists (with a new certification as of May 2009) are trying to provide solutions inside facilities. Many providers are adopting new case management protocols or enhanced utilization review to provide better support for documentation.

 

Just recently I heard of a national company started by physicians who are utilizing evidence-based physician "speak" to allay fears and defend language contained in patient records. It's a dizzying array of potential solutions - there's the vortex I started this article with. But which solution from the vortex will work for you?

 

As Dennis Hopper says in those TV ads, "my friend, you need a PLAN."

 

In a recent live Webinar on the RAC appeals process, we asked attendees from almost 100 facilities if they were ready for the RACs. One-third said they at least had a plan in place. Another third said they were talking about a plan. The final third said they had not done anything yet. Which third would you fall into? Are you still caught up in the vortex?

 

Perhaps we can agree that the answer to escaping the vortex (like the tornado) is best reached in this manner:

 

1. Assess the risk (where is it?);

 

2. Make preparations in advance (yes, maybe with us at RAC University);

 

3. Locate a basement (a base of operations, actually... how about medical records? I'm not joking!);

 

4.  Develop a survival plan (appeals, internal audits, appeals, external audits, process to assist MDs in documentation...did I mention appeals?)

 

Here's an example of one tool that we've created to help facilities improve their documentation. Essentially, it often fills  the need for a query to be sent to a physician.

 

We all know that coders and case managers always are asking physicians to be more specific, and physicians come back with a common refrain: "Tell me what to say!" Of course, it's not legal to tell them what to say. However, we CAN tell them what to cover in their documentation. A tool like this does exactly that.

 

Below is a screenshot of what is provided when a user asks for data for a common diagnosis: congestive heart failure, or CHF.

 

patdear-01-062509

 

As you can see, the tool provides a list of topics the MD needs to cover in his or her documentation to optimize the coding and therefore the reimbursement, which should be no more and no less than what the facility is entitled to receive. Use of a tool like this in some circumstances has reduced coding error rates ranging from a high of more than  50 percent to almost no errors within a month or two of use.

 

The above represents one straightforward and simple approach to improving physician documentation. Whatever method you use (as long as it is USED!), it should cue the physician along clinical diagnosis thought paths related to the individual patient event, be that an inpatient hospital, outpatient event or physician office setting. It also should be user-friendly and not involve elaborate multi-level screens requiring a tech support person.

 

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®.

Contact the Author: pat@edutrax.net

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