RAC Training: Get Ready For the RAC Appeals Process


The RAC auditing process can be challenging enough, but you must know when it’s worth the time and expense to appeal your audit. Read these healthcare training tips provided by our expert in a healthcare conference and know more.

Number one, you're going to have to work with the RAC request whether it's a demand of recoupment or request to get medical records, et cetera, whatever it is.

You'll want to be able to track all of the cases, all of the activity that’s going on with the RAC. You're going to want to track it. When did that happened? We sent this one to appeal on such and such a date. Here is what happened. We then said it to the second level or we did a rebuttal or whatever it is we do.

Now, you're going to have to develop personnel expertise. Somebody’s going to have to learn all of this stuff. All right, in so doing, you're going to have to do a lump sum sort of RAC team. Our expert mentioned in a compliance conference on-demand that every individual on the RAC team is dedicated just to RAC activities. But they're going to have to develop expertise to address the whole RAC issue.

You would later have to develop your own tracking software or require tracking software and care which if you developed yourself you of course are going to understand what's there. If you buy commercial software, you'll have learning curves. So take the time please to learn how to use it.

You're also have to develop a case management process. This is where you pull together all of the information. This is where you develop that physician paper. It is a clear concise convincing statement of why the RAC is incorrect, why they should be paid, why the documentation is appropriate, why it is medically necessary. This may even involve getting statements from physicians, et cetera.

And that's the next one. You may have to give the physicians medical staff involve and they must have enough RAC training on appeals. They're going to have to support rebuttals and appeals. And we don’t think generally this is problem because even the physicians realize that they themselves are subject to RAC issues. And so, you'll probably have a little more sympathy in that area.

You'll need to assess the overall cost benefit of activities, what is worth doing. Cost benefit thresholds for the appeal process. Now, it's not going to be much of a thresholds to do level one and level two. But if you're going to go beyond level two, you're going to want to have some thresholds in mind.

You're going to need to enhance your internal healthcare compliance program. Now, one thing you can do, one thing you can do and we hope there's really enough time to really do it, you can beat the RAC auditors to the punch. You can go in and look at your own claims.

Correct Use of Modifiers: Let's take the hot topic of the 25 modifier that’s starting to really come into the limelight. Maybe you should go out and look at all of your 25 modifier utilization into an honest assessment. Are we using it correctly? Is there documentation in place? Now, we can assure you the first thing you're going to ask is “Well, what are the standards? What are the documentation standards to support the use of the 25 modifier?”

And you know what, we don’t have a lot of information in that area. But anyway, you can do your own. You can do your own. Beat them to the punch if you have time to do that. And then you'll want to establish professional networks of contacts. Yes, the good news is you're not alone. Everyone hospital is going to go through this process. And so, you need to learn who your colleagues are at other hospitals around the state. And talk to them. And maybe you should even do conference calls once a month or something, whatever you need to do. Make sure you have those contacts setup.

And then of course you need to do or you can do at least exactly what the RAC contractors do. You could do your own data mining. You can reboot your own documentation systems. So you can do your own audits. You can do your probe healthcare audits. You can do any number of things. The big thing is to figure out what are your current vulnerabilities. Where are we weak? Where can we improve? Now, the problem with improving is that so often, we can improve it today but the last two years, we haven’t been doing so well. And that's what they're going to look at.

And then the hardest thing to do is to look into the future and ask yourself what possibly could be a RAC healthcare audit issue two years from today or three years from today. That's the hardest thing to do. Now, you can get some hints if you look at activity under CMS relative to issuing guidance. And one area where we have real problem right now as to what are called provider based clinics, provider based clinics and physician supervision, physician supervision and provider based clinics particularly if they are on campus but not inside the hospital building.
Suddenly, we've had a change in guidance, CMS says it's not a change. It's just a clarification.
What kind of information should be tracked?

You're going to want to keep track of RAC activity status, specific case information and categorization, particularly, if you're taking the case through the appeals process. If you're dealing with hundreds of cases, it would be all too easy to lose track.

And you'll want to look at the logical progression for any given RAC case. In some cases, you'll simply say, “Yeah, it was a mistake, we pay it.” In other cases, you're going to say, “Well, this is pretty questionable. Let's take it to the first level of appeal or maybe the second.” And then you're going to have cases where you are adamant about the fact that there was no overpayment and you're going to take it on up the ladder if you need to.

Now, developing this internal tracking system, well, you can do it yourself. And you probably can, everyone. If you're into databases, go to Microsoft Access. And then for those of you that know anything at all about programming even a little bit, you can use Visual Basic application to extend your capabilities. So, you can do this yourself.

Now, this infrastructure development, this tracking capability, always part of your cost-benefit equation that you must consider as per CMS guidelines.

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