Tim Johnson, Executive Director, Castle Rock Medical Group, gave the RAC Mini-Forum the following RAC advice.

Recommendations for all providers preparing for RAC audits:

1.  Don't buy into the hype. RAC auditors are not "bounty hunters" - they are medical collection companies hired by CMS to enforce evidence-based coverage policies, Conditions of Participation and claim submission criteria.
2. Adopt and implement CMS clinical, coding, documentation and claim processing requirements (CMS Payment Criteria) as the foundation of the hospital's financial structure.
3. Have honest, direct and timely discussions with your medical staff about CMS medical necessity and documentation requirements.
4. Review recent Department of Justice and Office of the Inspector General whistle blower cases and related settlements.  Several of these relate directly to RAC audit focus areas.

Recommendations for all providers preparing for RAC appeals:

1. Submit all medical records documentation available to support CMS Payment Criteria for the specific denial.  For providers with "hybrid" medical records, remember that everything you need may not be readily accessible in the EMR.
2. Objectively review all RAC denials and perform an internal CMS criteria-based case review prior to submitting your appeal.
3. Use CMS Payment Criteria and a comparative review of supporting medical records documentation as the basis for your appeal.
4. Review and become familiar with previous judicial rulings and Medicare Appeals Council cases that directly impact RAC audit focus areas.
5. Make operational changes to adopt CMS Payment Criteria, avoid future denials and alleviate the stress of potential Medicare fraud implications.

Publication Date: Thursday, February 25, 2010