Updated on: June 22, 2012

Utilization Review and Case Management: The Issue Gains More Traction, Plus Existence of a Provider Tracking System and Don’t Forget the OIG

Original story posted on: October 31, 2009

cbuck120dsFrom utilization review and case management to discovering the existence of a Provider Tracking System, our Thursday edition of RACMonitorEnews keeps a tight focus on RAC preparedness. And by the way, don't forget the 2010 OIG Work Plan.


Here's a taste of what we're working this week...


A recent Webinar on utilization review and case management sparked considerable interest and concern among attendees - so much so that we published a special bulletin and listed answers to the more amber-light questions that were posed to Webinar presenters Patricia Dear, RN, the president and CEO of eduTrax®, and Michele Madison, a partner in the law firm of Morris, Manning & Martin LLP.


And interest in the subject keeps gaining traction. To wit: an article we're working for this Thursday's e-news.


"If your hospital is not RAC-ready," cautions Barbara Vandegrift, RN, BSN, MA, "it's time to get ready, starting with the development of a utilization management plan." So advises Vandegrift, a senior healthcare consultant with Medical Learning, Inc. in this Thursday's edition of RACMonitorEnews. Vandegrift, in her article, says, "no matter whether the patient enters the facility through the emergency department (ED), endoscopy, cardiac cath lab, surgery or as a direct admission, it's important to know how the determination is made for an outpatient or inpatient status and whether medical necessity is a consideration."


RACMonitorEnews has been featuring articles on RAC tracking systems for months, but now Linda Fotheringill, Esq., in this Thursday's edition asks a very interesting question: are you aware, she wonders, that CMS has mandated that Medicare contractors have a Provider Tracking System?


The acronym is PTS, but it could spell trouble in the Medicare appeals process. Writes Fotheringill, "the PTS is to assist with CMS's overall goal of requiring Medicare contractors to analyze provider compliance with Medicare coverage and coding rules, and is to take appropriate corrective action when providers are found to be ‘non-compliant.'" But there's more, she notes. "It's of interest and concern when contemplating the Medicare appeal process because the information in the PTS might be unfairly prejudicial to the provider, and could cause the ALJ to decide a case unfavorably due to information unrelated to the particular case." What kind of information could be tracked on your hospital? Find out this Thursday.


And last but certainly not least, contributing editor Bret Bissey, FACHE, MBA, CHC and director of compliance for IMA Consulting, draws a distinction between the government audits of yesterday that involved long, drawn-out processes and those of today that are now quick and payback-focused/driven. In his article in Thursday's edition, Bissey notes that what is not different between the RAC initiative and previous investigations/areas of focus is that all providers have the opportunity to utilize the Office of Inspector General's Model Hospital Program Compliance as a proactive resource/planning tool to prepare for the RAC initiative. With remarkable dexterity, Bissey cuts and pastes highlights from this year's OIG Work Plan, revealing some very interesting areas of focus - even several that are very similar to the RACs' areas.


All this and more at RACMonitorEnews - the nation's single most important source of RAC news and information
Chuck Buck

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

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