Original story posted on: September 16, 2009

The Burning Questions for Hospitals: What Should You be Capturing and Tracking in Your RAC Audits?

By
Updated on: June 22, 2012

cengle120xED. NOTE: This is the fifth in an ongoing series being produced by Carla Engle for RACMonitor.


Deciding how your own internal processes are going to work once the RAC letters start rolling in is probably one of the most daunting tasks we all are grappling with at the moment.


Many hospitals already have mapped out their workflow and are on top of the process long before the letters are set to arrive. Part of that process is to ascertain HOW everything is going to be tracked to make sure that things are flowing in a timely manner and that nothing falls through the cracks.


A big decision in that respect is electing whether to use an automated tracking system to maintain relevant information for audits - not just RAC audits, but all the other audits coming down the pike as well. Obviously, tracking your dates and deadlines throughout the RAC process assures not only that the system moves efficiently and effectively, but that you avoid technical denials caused only by missed deadlines.


Deciding whether to use an outside vendor or create a database on your own demands a review of many factors. Your tracking tool should be able to handle information for multiple facilities and provider types (hospital, home health, physician group) and involve all of your RAC teams in the use of the system. Whichever tool you choose, the authors of the RAC Workbook (Find in RAC University Shop) recommend that the system has the capability to carry out these functions:

  • Create and track multiple task assignments
  • Attach electronic records and files on both the request and claim levels
  • Track the accountability of each step and person throughout the system
  • Send e-mail reminders of important tasks and approaching deadlines
  • Provide a "belt and suspenders" approach to assuring that all bases are covered in task and deadline assignments

Also, through your audit process, you should track the following information:

  • Demographic data
    • Facility names
    • RAC audit request numbers
    • Patient account numbers
    • Medical record numbers
    • Patient names
    • Health insurance claim (HIC) numbers
    • Admission dates
    • Discharge dates
    • Total billed charges
    • Total originally paid
    • DRG/APC
    • Principal and secondary diagnoses
    • Types of service
    • Admitting/Attending physicians

  • Requests
    • Number of claims requested
    • Postal/FedEx tracking numbers
    • Names of auditing bodies
    • Dates of initial request letters
    • Dates initial request letters received
    • Confirmation that records were received by RAC
    • Date records sent to RAC
    • Number of pages sent/reconcile claims to request letter
    • Track copying costs vs. reimbursement

  • Determination
    • Reasons for the denials
    • Number of denied claims
    • Results of the audit
    • Types and trends of denials
    • Date review results letter sent and received
    • Date demand letters sent and received

  • Recoupment
    • Dates of reimbursement or recoupment by CMS
    • Amounts of reimbursement or recoupment

  • Appeals
    • Data to decide whether to launch a discussion period
    • Data to decide whether to launch an appeal (and, if so, at what level)
    • For each appeal level:
      • Status of every appeal
      • Basis of appeal
      • Date appeal letter sent from facility
      • Appeal due date
      • Date appeal decision due back from RAC
      • Date appeal determination received
      • Appeal outcome (upheld or overturned)
      • Whether to move to the next level of appeal


Additionally, it is vital that a number of these following elements also exist within the reporting tool to ensure that the workflow is indeed flowing!

  • Attachments
    • Attach copies of medical records, correspondence, and appeals directly to the claim

  • Communication
    • All verbal and written communication (calls, e-mail, any correspondence), performed both internally and between the facility and the auditor

  • Tasks
    • Who is responsible for what, and when is it due?
    • Make sure task assignments are communicated quickly to those responsible for completing them, and that management is kept informed

  • Timelines
    • What is soon due and when?
    • How can I manage my team and keep them informed that big work demands are coming up?

  • Financial impact and risk to the organization
    • Reports that indicate at-risk dollars in each level and corresponding statuses
    • Trending and analysis that shows patterns, both with providers and RACs

  • Compliance
    • Indicators of reportable events
    • Broader compliance issues that need further investigation and auditing

  • Duplicate claims
    • Are you tracking duplicate claims to ensure that another auditing body hasn't already reviewed this claim?

  • Other audit types
    • Are you tracking other types of audits?  MICs?  ZPICs, QIOs, MACs, CERT, etc.


If you cover these bases with any tracking tool, you can be assured that you have a strong chance of exercising your right to work through the appeal process.


Those of us who have tried to manage with a spreadsheet or an Access database can offer some advice to those of you who are considering this option - DON'T! Your return on your investment is immediate and powerful with an automated option that ultimately provides many tools in your RAC tool belt.


About the Author


Carla Engle, MBA, is a product manger for MediRegs, a Wolters Kluwer company. Her 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 theRreimbursement Training Department with HCA.  For several years she 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.


Contact the Author

carla.engle@wolterskluwer.com

 

References

    Narain, A., et al. (2009). Recovery Audit Contractor Workbook. Chicago: CCH.

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