Revenue Cycle

A few minutes with Donna Wilson

Recovery Auditor Report, October 14, 2010

Name: Donna Wilson, RHIA, CCS

Title: Senior Director

Company: Compliance Concepts, Wexford, PA

Quick-hit RAC background: Wilson has been involved in the RAC program on many levels — having had first-hand experience in the demonstration project as Revenue Integrity Manager in charge of RAC coordination at a large acute care facility. Donna is now on the consulting side and currently assists clients throughout the nation on the RAC process, as well as best practices on coding and documentation. She is an active volunteer with AHIMA.

  1. What are some (or just one) of the most common errors you’ve seen hospitals make when it comes to the RAC process? Failure to appeal RAC denials. Fighting RAC denials is a time-consuming process, and with the current state of budget cuts, staffing can also become an issue. Hospitals should consider outsourcing appeals, especially on high-dollar claim amounts and on cases where documentation and coding is supported in the medical record.
  1. What do you think will be the next big thing in the RAC world? Medical necessity issues, definitely. Think about it: RACs are able to deny the entire claim versus the DRG dollar difference.
  1. What should providers be doing to prepare for the expansion of RACs into Medicaid? Hospitals and provider should make sure that their release of information area is ready for the volume of record requests.
  1. What is one word of advice you can give to hospitals for preparing for the next phase of RACs? Educate yourselves on best-practice documentation, since many RAC denials are based on inconsistent and missing documentation.

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