No matter how you look at it, the Recovery Audit Contractor (RAC) program is not an easy problem to deal with, and it is not going away. So, the prudent approach is to put plans in place to systematically navigate the process and incorporate RAC activities into daily work flow. Following are some tips to help manage your organization’s RAC audit process:
- Form a Multidisciplinary Team of Stakeholders
- Determine a Process for Responding to a Medical Record Request
- Create a System to Track the RAC audit process
- Plan for the Appeals Process
- Educate Staff on the RAC Process
- Conduct An Internal Audit
Form a Multidisciplinary Team of Stakeholders
The RAC process affects many disciplines throughout a health care organization, including the health information management, case management, patient financial services, administration, and compliance departments. By pulling a management team together and involving these and any other identified stakeholders on the team, organizations can ensure a comprehensive approach to managing the RAC.
Regular communication with your RAC contractor can also be beneficial. “By talking frequently with your RAC, you can get to know what they expect and how they intend to proceed with the auditing process. This information can help you plan how you are going to address the process,” says Brian Flood, managing partner for KPMG.
Determine a Process for Responding to a Medical Record Request
Under the demonstration project, when a RAC requests medical records from your organization, you have 45 days in which to provide those records unless you ask for an extension. “This is not a lot of time, particularly when your organization is addressing other demands for medical records,” says Gloryanne Bryant, Senior Director Corporate Coding HIM Compliance for Catholic Healthcare West (CHW). “By developing a centralized process for prioritizing, pulling, copying, and mailing these records, organizations can ensure they don’t go over the allotted time.” Some things to keep in mind when designing such a process include the following:
- Determine a way that RAC medical record requests receive priority attention
- Consider how you will quickly obtain any requested medical records that are stored off site
- Talk with the individuals responsible for copying medical records - whether they are staff members or venders - to make sure they are aware of the urgency of these requests
- Use a mailing venue that offers a tracking system, so you can follow-up on the status of mailed records
- Prepare an invoice for copying and determine who is responsible for following up on that invoice to ensure it gets paid
- Consider when your organization should seek an extension and who will be responsible for asking for that extension.
- Consider if additional staff is necessary to meet the demands of the RAC audit process
Create a System to Track the RAC Audit Process
To help manage the RAC process, it can be helpful to have a tracking system that houses all important information relating to the process. “This system may take the form of a spreadsheet and should be available on a shared drive, so all members of the RAC management team can access it,” says Bryant. Information to house in the spreadsheet may include the following:
- Medical record numbers
- Account numbers
- Dates of service/discharge
- Postal tracking numbers
- Original charges
- Reasons for analysis
- Results of analysis
- Dates of take back
- Financial impact
- State of appeal
- Comments
- Total number of records requested
- Total number of claims denied
- Total financial impact to the organization
“The tracking system should be updated regularly, such as on a monthly basis, so everyone can have a current picture of what is happening,” says Bryant.
Plan for the Appeals Process
Although health care organizations participating in the demonstration only appealed 11.3% of the denied claims, it is important to have a process in place for launching an appeal. “Organizations should consider creating a standardized appeals letter that can be customized for each appeal,” says Bryant. “Such a letter would include things like the case number, rationale for the appeal, and your organization’s recommendation. Appeal letters should be drafted with legal oversight to make sure all included language is appropriate.”
Educate Staff on the RAC
“Education about the RAC is critical so that every staff member involved with the process understands his or her role and the importance of that role,” says Bryant.
In addition, staff should be educated on how to correct issues revealed by the RAC audits. Some information to communicate when educating staff includes the following:
- Analysis of RAC findings
- Systemic issues revealed in the findings
- How to correct those issues and avoid similar findings in the future
“By responding to the findings of the audit, your organization can address systemic issues that could help you prevent denied claims in the future and diminish risk,” says Bryant.
Conduct an Internal Audit
Taking a proactive approach to the RAC audit may be the most effective way to streamline the process. “RACs are focusing on the short stay patterns of institutions, admission errors, and other low hanging fruit,” says Flood.
“Looking proactively at your organization’s short stay patients and reviewing the explanations of why they were short stay may help identify potential issues that need addressing. Using a multidisciplinary team to perform this audit can be helpful and gain you different perspectives.”