Appealing RAC Audits with Teamwork
Florida’s Bethesda Memorial Hospital, a 401-bed community, not-for-profit hospital, is one of the organizations that witnessed the impact of RAC audits firsthand. According to Joanne Aquilina, vice president of finance and CFO, the audits soon evolved into an overwhelming volume of work.
Thousands of Records Requested
“At first, we were responding to 10 or 20
complex reviews a month for specific DRGs,” she
explains. “The auditors zoomed in on cases where
coding rules were not being followed. Then, they
started looking for short lengths of stay—such
as Friday admissions and Monday discharges—so
the requests jump to about 50 a month.”
“By the time the demonstration was wrapping up,
we were getting 250 requests a month,” says
Aquilina. “That really taxed our HIM [healthcare
information management] department heavily.
Overall, we provided 2,200 records from August
2005 to November 2007—about 7 percent of our
total number of cases for the period under
review.
A Team Approach to Appeals
For Bethesda, the appeals process was
illuminating. “We appealed a lot of the
one-day-stay recoupments,” says Aquilina. “Some
of the appeals are still incomplete, but we’ve
won more than half of the appeals we have filed.
The would be my biggest recommendation: Fight
the recoupments.”
Developing standard processes and an
organizational structure for appeals is
paramount, according to John Orsini, corporate
vice president of finance at San Diego-based
Scripps Health. “These audits consume enormous
resources,” he says. “So you need to quantify
that time demand and build it into your
workflow. And those processes should assume that
the RAC will deny every case. An effective
strategy requires tremendous cross-department
collaboration and it affects IT, HIM, patient
accounts, care management, and other areas. You
can’t assign it to a single person—you need a
multidisciplinary team to work through these
issues.”
As an example of the type of leadership that can be in place, consider the structure used for managing RAC processes at Bethesda Memorial Hospital. Bethesda’s internal RAC team oversaw process flow from receipt of a record request through the denial or appeal process. The team included such representatives as:
Director of HIM
Director of patient accounting
Director of quality improvement
Assistant vice president of organizational effectiveness
Vice president of finance/CFO
Regardless of how a team is structured, its
objective should be to develop formal processes
with clearly defined responsibilities that are
linked to deadlines. Successful management of
RAC inquiries depends on a well-timed, organized
approach.
This article is pulled from HFMA’s special
advertising section, Readying for the RACs:
What You Should Know, March 2009.
Read the comprehensive report.