ACVP: Dont fear the RAC

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Orlando, Fla.—Cardiovascular Business News sat down with Patricia Dear, president of EduTrax, an online coding, compliance and billing resource for healthcare providers, to discuss Medicare’s recovery audit contractors (RACs), who make a percentage of overpayment monies they recover for the government. Dear was a speaker at the annual meeting of the Alliance for Cardiovascular Professionals (ACVP) lin March.

Cardiovascular Business News: What do cardiovascular medicine providers need to know about a RAC audit?

Patricia Dear: What has always been true about the complexity and completeness of documentation is still the cornerstone of good bookkeeping. RACs look for easy target areas. For example, elective, scheduled and diagnostic procedures where patient class may be outpatient but mistakenly recorded as inpatient. Cardiovascular providers need to examine these types of records in real time so that the bill, at least in the front end, goes out clean. They also should do many post-retrospective reviews, since RACs can review claims dating back to October 2007.

CVBN: Do you have recommendations for people in the midst of a RAC evaluation?

Dear: Any people involved in a RAC request should make a good effort to review the documentation and the documents before they are submitted, so they know what is being submitted. They should launch an aggressive appeal, well within the appeal timeframes. They should track their own deadlines and not wait for the RACs to notify them. Again, it should be personal to their program; it is their revenue at stake.

CVBN: Can you list some easy targets for RACs in the cardiovascular arena?

PD: A diagnostic elective cath, for example, with stent insertion where the patient status is relatively stable. One would anticipate it’s likely an outpatient procedure. The communication through the record, perhaps, is unclear to those at the billing end. The post-anesthesia recovery unit is closing and the patient needs a bit more recovery time. There’s never any intent to make that patient an inpatient stay. But somehow it’s communicated incorrectly to the folks who do the billing and admissions work.

Other easy targets are pacemakers and elective change-outs. Anything that has the words “scheduled” and/or “elective” and/or “diagnostic” in the face of an otherwise appearing to be stable patient event should be reviewed. “Acute care,” “critical” and “complex comorbidities”—these should be fairly easy to support in the documentation to have a clear inpatient event. But someone at that end at least should have an understanding of the admission criteria for an inpatient stay versus an outpatient activity.

CVBN: Are people panicking? If so, how can they diminish the fear factor?

PD: Yes, they are panicking and they become paralyzed in the face of a RAC audit. Preventative measures are the best course of action. Arm yourself with knowledge of the process. Don’t get caught up in anger. With the economic times we’re living in, every dollar matters. If you’re involved in understanding what the processes are and involved in understanding how you can benefit your organization, your physician and your community, I think that takes away some of the sting.

And remember, there are opportunities to increase revenue, especially by identifying areas where facilities have been underpaid. RACs won’t audit these areas as aggressively as they will overpayments. It’s up to the provider to seek them out. For example, areas related to transfer DRGs, where certain categories of DRGs are shared between the inpatient acute setting and the post-acute provider. Other opportunities exist as well, but facilities often tend to focus on the fear factor. The best approach is to be proactive, be prepared and be confident with your data.