There is a RAC Audit in Your Future Take Cover

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There is a RAC Audit in Your Future Take Cover!

• Jean S. Clark, RHIA, CHSA
• GHIMA
• August 21, 2008

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Objectives

• Overview of RACs to date
• How to prepare
• Our experience so far

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What is a RAC?

• Demonstration project potential overpayments in
  2003 by 19 billion. Project implemented in 2006
  to determine if RACs would be a cost-effective
  method to ensure that improper payments to
  Medicare providers are detected and corrected.
• RAC Medicare Recovery Audit Contractor
• Purpose To take your money back!
• Where
• California, NY, Florida

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Results ?

• 657M in overpayments in NY, CA, FL
• Reportedly returned 247M to Medicare Trust Fund

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What were the reasons ?

• Incorrect coding 42
• Medically unnecessary, or insufficient
  documentation 41
• Other 17

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What is a the focus?

• Overpayments
• Underpayments
• Guess what the focus is here? Not underpayments
  for sure!
• Auditors paid on what is recovered
• Hospital must appeal decisions, money
  automatically taken from MC remittance

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Types of Reviews

• Part A Complex Medical records are requested
  and reviewed
• Part A and B Automated No medical records
  requested, data mining
• Part B DME, Drugs, Renal Dialysis Medical
  records are requested and reviewed
• Rehabilitation Hospital Medical records
  requested and reviewed

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Complex Reviews Part A

• Inpatient short stays
• Overuse of observation
• Medical necessity
• Coding

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Complex Reviews DRG Targets

• DRG 85 - Pleural effusion with CC
• DRG 86.22 Debridement
• DRG 397 Coagulation
• DRG 416 Septicemia

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Automated ReviewsPart A and B

• Inpatient only procedures
• 72 hour rule
• Discharge disposition code assignments
• Units of service

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Medicare Secondary Payer (MSP)

• Medicare Secondary Payor (MSP) where Medicare
  should have not been the secondary payor.
• Claims review claims and medical record

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Appeals

• Must decide what to appeal
• Some hospitals appeal everything
• Define the process who is responsible, etc.

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RACs Expand

• Summer 2007
• South Carolina
• Massachusetts
• Arizona

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What States are Next?

• By January 2009 or later
• Alabama
• Georgia
• Kentucky
• Louisiana
• Maryland
• Mississippi
• North Carolina
• Tennessee
• Virginia
• Washington DC
• West Virginia

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Get Ready NOW!

• It takes a village
• Form a RAC team key stakeholders are
• HIM, BO, IT, Finance, Coding, Case Management,
  Compliance, Legal (dont forget your Copy
  Service, records storage if off-site)
• Look at your data in regard to focused DRGs
• Review your medical necessity process
• Case management focus on one, two, three days
  inpatients and Observation
• Check your coding

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Get Ready NOW!

• Identify responsibilities
• Who is the point person?
• Develop a database
• Educate staff, including physicians
• Consider implementing a clinical documentation
  program
• Communicate with your vendors (copying service,
  records storage)

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Get Ready NOW!

• What about staffing?
• May have to add staff, especially in HIM
• Outside consulting?
• Consider using outside consulting to assist with
  appeals

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Develop a Database

• Initial request - BO
• Important parts of the medical record - HIM
• Evidence of receipt by RAC - HIM
• Dollars, pre-review, post-review(denial) - BO
• Type of denial Revenue Integrity
• Outcome of denial Revenue Integrity
• Medical record in repository for RAC team to
  review - HIM

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Flow of Process

• Letter received in lock box
• Business Office enters data regarding initial
  request (data flows into database from other
  systems)
• BO fax requests to HIM and also emails RAC Team
• HIM retrieves medical records
• HIM reviews records for completeness
• Copy service scans records into secured
  repository and prints records
• HIM oversees mailing of records return receipt
  requested, priority mail
• FedEx picks up records
• HIM tracks receipt of records
• HIM enters information into database
• HIM files paper records on RAC file shelf

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Impact on HIM

• Identified a point person for the process long
  term HIM staffer familiar with the content of the
  medical record
• Added 2 FTEs to analyze records for RAC

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Impact on HIM

• HIM has the lions share of the work!
• Burdensome
• Costly
• Time-consuming
• Frustrating

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South Carolina RAC

• Health Data Insights (HDI)
• Based in Las Vegas with a satellite office in FL
• First requests in October, 2007, ended in
  February, 2008
• Requested records back to 2004 and through 2007
• New RAC soon to be announced

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SC Survey Results

• Overpayments - 28,500,00
• Underpayments - 190,000
• Hours invested by hospitals 8,841
• Rebuttals 939
• Appeals anticipated 825
• From SC survey 2/29/08

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The Focus So Far in SC

• One day stays
• Declots of AV fistulas
• Chest pain
• Heart caths
• CHF
• Back pain
• Syncope

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The Focus So Far in SC

• DRG 468 principal diagnosis does not match
  principal procedure
• DRG 150 lysis of adhesions
• DRG 416 - sepsis
• DRG 515 - Defibrillators

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Roper St. Francis

• 406 record requests
• 2004-2007
• 162 of the 406 requests were 1-day stays
• 99 of the 162 were cardiology

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Roper St. Francis

• DRG 076 transbroncial lung biopsies
• DRG 088 COPD
• DRG 120 Declots
• DRG 125 Heart caths
• DRGs 150/151 Lysis of adhesions
• DRG 127 CHF
• DRG 182 GI
• DRG 243 Medical backs
• DRG 515 Defibrillators may rebill as
  outpatient
• DRG 416 Sepsis
• DRG 468 Unrelated.

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Roper St. Francis

• Coding issues for us
• 2 - 468 principal diagnosis does not match
  principal procedure
• 2 150 lysis of adhesions must document
  extensive or dense

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Roper St. Francis Automated Reviews

• 168 claims reviewed for discharge disposition
• 90 of the 168 were changes 03 (SNF) to 04
  (Intermediate Care) (underpayments!)
• Units of service (19) blood transfusion, rehab
  service, neulasta drug infusions
• will become a complex review with RAC expansion

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RAC Review Process
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Appeal Process
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Roper St. Francis Appeals Process

• Revenue Integrity Department manages denials and
  appeals process
• Sends to appropriate department for review and
  response, for example, coding issues to coding
  data quality specialist, medical necessity to
  case management
• Use outside consultant to review select denials

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What SCHA is doing to help.

• Educational programs
• Frequent emails
• Monthly conference call with RAC

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What to look forward to

• RAC identified for SC by August
• May expand to MD practices
• May increase number of records requested (no more
  than 100 per hospital so far)
• Claims after 10-01-07 (hopefully!)
• OIG could go back beyond this date

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In closing.

• Identify a RAC team start meeting
• Identify a RAC point department to receive
  requests HIM, BO, Revenue Integrity, Compliance
  - whatever works best for you
• Develop a database
• Consider HIM staffing issues
• Develop response, rebuttal, and appeals process
  identify point person/department
• Monitor RAC compliance pro-active and
  retrospective audits

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In closing.

• Education is a key process
• Coders, Case Managers, Nurses
• Medical Staff show them the data! Especially
  their own!
• Ticket to the hospital type of admission form

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In closing..

• Stay calm!
• Be prepared!
• Contact me jean.clark_at_ropersaintfrancis.com