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WELCOME TO THE RAC REPORT Welcome to The RAC Report, brought to you by HCPro?s Revenue Cycle Institute. Our new bi-weekly e-newsletter is your authoritative source for news, tips, and training for the Medicare?s Recovery Audit Contractor (RAC) program. The RAC nationwide rollout begins no later than January 1, 2010, and we will prepare you to be "RAC ready" by offering best practices to avoid RAC recoupments. Click here to learn more about The Revenue Cycle Institute.
Claim closed: How the demonstration can teach us about RAC-withdrawn reviews
Nothing is ever easy for providers in the ever-fluctuating realm of RACs, and the latest spell of operational hiccups heard nationwide is no exception.
No hospital necessarily wants to receive an additional documentation request (ADR) from the RAC, yet when it arrives, it’s essentially not surprising. But when a provider receives a follow-up letter from that RAC informing the facility that the claim is closed and the audit has been rescinded, it may throw that hospital for a loop, according to a revenue integrity auditor from a hospital in Region A (DCS).
“We recently received an automated letter notifying us that Medicare made an overpayment related to a CCI edit with an amount and brief description of the claim associated with the overpayment,” she says. “When I called [the RAC] to question the letter, a customer service representative told me that they’d rescinded the audit because it was ‘outside their audit scope.’ ”
She continued, “I had to ask for a rescind letter to be sent to me stating this information. We are monitoring the account to assure that money isn’t recouped by NGS on day 41, and this has prompted us to do an internal investigation related to this information.”
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RAC talk: A few minutes with Elizabeth Lamkin
Name: Elizabeth Lamkin
Title: President
Company: Dalzell Consulting Group, Inc. Hilton Head, SC
Quick-hit RAC background: Elizabeth has 20 years of executive experience including the position of CEO of multi-hospital systems. Most recently she served as president of Hilton Head Regional Healthcare where she was part of the South Carolina RAC demonstration project. Elizabeth successfully navigated the RAC process and implemented a system to ensure appropriate billing compliance and win RAC appeals. Elizabeth is currently president of Dalzell Consulting Group, Inc. specializing in systems improvement to improve margins.
What are some (or just one) of the most common errors you’ve seen hospitals make when it comes to the RAC process? The most common error I have seen hospitals make is poor documentation of medical necessity and continued stay. The by-product of poor or no documentation is inaccurate coding and the inability to appeal RAC findings. Another error hospitals often make is having an out-of-date chargemaster. This can lead to patterns of incorrect billing for such things as dose vs. unit billed. Physicians are also at risk in this area.
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From the field: Recoupment before receipt of demand letters
The Revenue Cycle Institute recently had a brief conversation with Karen Sagen, managed care leader at Bellin Health Systems in Green Bay, WI, on a recent problem that has been confounding a number of providers nationwide.
Question: There has been talk out there about a confusion issue involving RACs. Apparently some providers have been seeing recoupment before the receipt of demand letters. Can you comment on this?
Answer: We have seen a lot of this and it’s definitely causing some confusion. What is actually happening is that the Medicare Explanation of Benefits (EOMB) shows the N432 code (a RAC denial code that appears on the remittance advice, which is a notice of payments and adjustments sent to providers, billers and suppliers.) and if you look at that entry, it looks as though money has been recouped. However, what is actually happening is that the N432 is attached to the claim at the time the demand letter is produced, which in turn activates the N432 on the EOMB.
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CMS releases additional documentation request limits for providers
On November 10, CMS-in response to feedback from the RACs, providers/suppliers and their associations-has modified the additional documentation request limits for the RAC program.
View the new ADR limits for providers here:
http://www.cms.gov/RAC/Downloads/ADRpr.pdf
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Recent RAC activity
CGI adds new RAC issue in two separate categories
CGI, the RAC for Region B, added two new RAC issues -- one for outpatient claims and one for professional claims --to its CMS-approved list for providers in all Region B states.
View the new issues here.
Connolly adds 37 new RAC issues across two categories
Connolly Healthcare, the RAC for Region C, added 37 new issues —30 for DRG validation claims and 7 for medical necessity claims —to its CMS-approved list this week for providers in all Region C states.
View the new issues here.
HealthDataInsights adds new RAC issue for Part A inpatient claims
HealthDataInsights, the RAC for Region D, added a new RAC issue for Part A claims review to its CMS-approved list this week for providers in all Region D states.
View the new issue here.
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Revenue Cycle Institute issues free monthly tool
Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. We hope you find this month’s tool—a checklist to follow for using condition code 44—helpful when it comes to billing an outpatient claim with condition code 44.
Editor’s note: Access the free tool by clicking here. This checklist was submitted by Deborah Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK. Additional tools can be accessed by clicking here.
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| RAC Report Advisory Board |
Nancy J. Beckley, MS, MBA, CHC
Certified Healthcare Compliance
Bloomingdale Consulting Group |
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Yvonne Focke, RN, BSN, MBA
Director, Revenue Cycle & Integrated Care Services
St. Elizabeth Healthcare |
Deborah K. Hale, CCS
President/CEO
Administrative Consultant Service, LLC |
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Nancy Hirschl, BS, CCS
President
Hirschl and Associates |
Kimberly Anderwood Hoy, JD, CPC
Director of Medicare and Compliance
HCPro, Inc. |
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Elizabeth Lamkin
President
Dalzell Consulting Group, Inc. |
Stacey Levitt, RN, MSN, CPC
Director, Patient Care Management
Lenox Hill Hospital (New York City, NY) |
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William Malm, ND
Healthcare Consultant
Craneware PLC
w.malm@craneware.com |
Tanja Twist, MBA/HCM
Senior Director of Operations
Adreima
tanja.twist@gmail.com |
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Joseph Zebrowitz, MD
Executive vice president
Executive Health Resources |
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