Case Management

Mentor moment: RAC talk with Kimberly Anderwood Hoy

Case Management Weekly, November 17, 2010

Kimberly Anderwood Hoy, Esq., is director of Medicare and compliance for HCPro, Inc., and an expert on all things Medicare. She recently answered a series of questions for our sister blog, The Revenue Cycle Institute, about Recovery Audit Contractor (RAC) topics. Notice that she mentions the fact that RACs are setting their sights on medical necessity, which means case managers will play a key role.

What was one of most common front-end problems hospitals may have had that led to RAC audits and/or recoupments?

I’m not sure that there’s anything specific. I think that if there’s a strong compliance plan that is looking out for errors, a facility should and can be in good standing. In other words, the best defense is a strong compliance plan.

Was there any one particular CMS-approved issue that may have given providers the most trouble this past year, and why?

If you went by the last year, there hasn’t been one particular issue, but rather a number of issues across the board.  What’s been giving providers the most trouble are the operational difficulties the RACs have been having with everything from records receipt to timing of denial notices and recoupments.

When it comes to a facility’s RAC team, is there a specific member of the team that is the most integral?

In my opinion there are a few members that are most important, and then there are other members that—if a hospital can afford it—are helpful and valuable to the team as well. I do think a compliance auditor is an extremely vital member. I also think that somebody from case management is valuable, too, because the majority of the errors that caused problems in the demonstration were medical necessity. In addition, you need somebody from the business office or billing area who understands the appeals process and billing aspect that can truly determine whether an error was an overpayment or an underpayment.

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