If there has been one coffer that has been jingling right through the so-called economic downturn it surely has to be this. No!! We don’t mean the Federal Reserve, but the rather humbler Medicare Recovery Audit Program or RAC in short. The first quarter of this year has yielded a magnificent $ 750 million, nearly $100 million more than the last. So, it looks like at least someone is doing their homework when it comes to healthcare.
But unfortunately, this is certainly not good news for the various hospitals, small clinics, and independent practitioners, already reeling under the effects of reduced payments from the federal insurance programs. More than anything it only serves to prove that payment criteria have become very stringent and non-adherers have to pay a heavy price. It has been estimated that since the starting of the program a whopping $4 billion dollars has been extracted by the four RAC Auditors; Connolly, DCS, HealthData Insights, and CGI.
Some Important Facts about RAC Audits:
1. A hospital or a clinic may have to spend upwards of $40,000/year to manage a RAC process.
2. Outpatient billing errors contributed to over 40 percent of the dollars recovered.
3. Cardiovascular procedures topped the list in overpayment recovery, while minor procedures and other treatments billed as inpatient when an outpatient setting would have sufficed, came in next.
4. Your hospital/clinical staff might have to spend nearly 500 hours a year dealing with the RAC process.
5. Another version of improper CMS payments involves the transfer of funds in the opposite direction. Providers are being underpaid by nearly $300 million every year by Medicare, unless there is an internal process in your clinic to deal with it.
5 Crucial Tactics To Be Followed:
a. Know Your Curve: RAC’s use complex software and/or complex audit practices to determine if you are overcoding. Thus if your codes fall outside that nice fat region of a Bell’s Curve for Procedural Codes, chances are high that you may have garnered unnecessary and harmful attention from CMS. Thus, make sure your inhouse medical coding team or your outsourced medical coding vendor does not use the more general codes without a solid rationale, and follows the most important thumb rule of a medical coding process, which is going for the next highest code for more specificity.
b. Modifiers: Modifiers, especially 59 & 25, need to be used judiciously since they mainly accompany outliers, and thus may drawn unsolicited attention.
c. Satisfied Patients: Don’t send back grumpy patients, who may call up the payer’s office (including CMS) often times and direct their roving eyes onto your practice. Exquisite patient support desk should significantly decrease the chances of the above, and even at times when patients are not happy about certain charges billed to them, they would contact your clinical staff first rather than take it up with the payers.
d. Compliance Plan: Your clinic needs an internal compliance program just to make sure your medical billing team or medical coding team is functioning properly. This makes sense even if there had been no RAC guillotine hanging over your head. That is because a pursuit of quality and setting internal benchmarks for the same is going to aid any process’s growth in the long run.
e. EHR Awareness: Make sure your clinical staff know their way around the various templates of your EHR; else there is every possibility that some redundant material from an altogether different patient may make its way into an unrelated patient’s electronic medical records. A partnership with an EHR Support Vendor to help you gain this awareness may also be a good idea.
CONCLUSION: Finally, if you find that your internal medical billing and coding staff are unable to cover all of the above ground; it would be wiser and certainly simpler to transfer this responsibility onto an existent medical billing vendor. As experts in the medical billing domain they stand a better chance in helping you to implement the above, and thus aid you in avoiding/getting through an RAC audit.
