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CMW Sneak Peek: Manage your fear of the RAC

Case Management Weekly, November 12, 2008

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CMS’ Recovery Audit Contractor (RAC) program elicits feelings of fear, but Brenda Keeling, RN, CPHQ, CPUR, president and owner of Patient Response in Milburn, OK, says fear is the last thing you should feel when faced with a RAC audit.

Remember that RACs cannot randomly select claims or target one “solely because it is a high-dollar claim,” according to the draft Statement of Work. A RAC can only “target a claim because it is a high-dollar claim and contains other information that leads the RAC to believe it is likely to contain an [over- or underpayment].”

Nancy Hirschl, BS, CCS, president of Hirschl & Associates in Laguna Niguel, CA, and an HCPro RAC Report advisory board member, says the “other information” could include:

• Diagnosis codes that may be incorrectly coded based on RAC experience in the private health insurance arena
• Diagnoses that often present physician documentation insufficiencies
• Procedure codes that do not correlate with diagnosis codes
• Procedure codes that may indicate inappropriate site of service/inpatient status
• Incongruent charge to payment comparison
• The belief that the claim payment was not consistent with Medicare payment policy

Hirschl says you should identify areas the RAC may target before the RAC arrives, develop strategies to defend your data, and improve case management protocols.

Check out the November 2008 issue of Case Management Monthly to get the full story, and discover all the benefits of being a Case Management Monthly subscriber!

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