Case Management

Mentor moment: Position your resources to prepare for RAC medical necessity audits

Case Management Weekly, September 15, 2010

The recovery audit contractors (RAC) have certainly been busy lately. CMS gave permission to three RACs (Connolly Healthcare, Health Data Insights (HIS) and CGI Federal) to begin medical necessity audits.

The good news for case managers is that the RACs’ targets are not very surprising. If you check your hospital’s CERT and PEPPER reports you may find that some administrators have already flagged these issues.

Hopefully, your organization has been working on improving utilization in these areas. However, if you have not had the time or the staff required to focus on managing Medicare medical necessity, you may be feeling overwhelmed by the additional admission reviews that you will need to complete during the initial inpatient day.

Albert Einstein said insanity is doing the same thing over and over again and expecting different results. If hospitals don’t modify processes to meet increased RAC scrutiny we can’t hope to protect our Medicare revenue. Adding case managers is an option, if you can find and afford them. Unfortunately, is not an option for many facilities. 

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