Health Information Management

News: Take RAC lessons to heart

CDI Strategies, March 4, 2010

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Those who lived through the RAC demonstration project learned valuable lessons along the way, lessons that CDI professionals can use as the RAC reviews become permanent and audits begin to take on more medical necessity and documentation concerns.
One of the most important lessons Tanja Twist, MBA/HCM, director of patient financial services for Methodist Hospital in Arcadia, CA, learned from the demonstration project was the need to diligently track and monitor all correspondence to and from the RAC.
“This goes beyond tracking the date you send or receive the actual documents (e.g., determination letters, medical record requests and appeals) or send the medical records. You should include tracking the receipt of the documents by the RAC to ensure you are responding timely.”
Send everything via certified mail with a return receipt, she suggests. And make sure everyone-not just the mailroom-knows what RAC documents look like so that correspondence isn’t lost or left on someone’s desk.
Tracking appeals is the single most important way to survive a RAC audit because it allows you to prioritize your appeals, says Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City.
“This way you can spend your available time where you get the biggest bang for your appeal effort.”
Having a strong physician advisor program with an active physician participant reviewing and interceding when appropriate helps too, says Yvonne Focke, RN, BSN, MBA, revenue cycle director at St. Elizabeth and St. Luke Hospitals in Covington, KY.
It’s important for hospitals to regularly assess the effectiveness of their concurrent Medicare admission review processes, according to Joe Zebrowitz, MD, executive vice president for Executive Health Resources. Hospitals have to get the Medicare patient’s status correct every time.
Establish a strong utilization review plan that follows Medicare’s Conditions of Participation. But a good plan does not solely ensure good results. You must make sure that the plan is being followed every day and that your case managers are using criteria to review all Medicare admissions and that every case that does not meet the criteria is undergoing a second-level review by a physician advisor, Zebrowitz says.
This physician advisor must be well versed in medical necessity regulatory guidance and use evidence-based medicine and risk stratification protocols to establish correct patient status. Your organization should also conduct retrospective audits on an ongoing basis to identify inappropriate medical necessity determinations from the past and self-disclose any errors, he says.

Zebrowitz also calls out the importance of physician education and collaboration. Many physicians working in hospitals do not have a firm understanding of the regulatory guidance on inpatient versus observation status certification and, more importantly, the ramifications of getting the status wrong, he says.

It is your hospital’s responsibility to educate your physicians on the importance of documenting all of their concerns and findings in order to demonstrate medical necessity for all inpatient admissions, says Zebrowitz.

Editor’s note: Learn more about the RAC audit and appeals process at The Revenue Cycle Institute. Look for additional information on how CDI programs are responding to RAC requests for written query records in the April edition of the CDI Journal, and hear ACDIS members and ACDIS advisory board leaders discuss the latest RAC news in the online archive of Quarterly Conference Calls.

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