Due to the success of the Recovery Audit Contractor (RAC)
demonstration CMS now plans to recoup more monies as the permanent RAC
is rolled out to all states by 2010.
Now is the time to prepare
for increased scrutiny of your Medicare claims; the RAC's will be in
your state soon, if they are not already there.
The Department of
Health and Human Services and Office of Inspector General provide a
model compliance program to provide healthcare providers with guidance
to prepare for the RAC. The seven elements of a model compliance
program are as follows:
- Designation of a compliance officer and compliance committee
- Development of compliance policies and procedures
- Establishment of open lines of communication
- Appropriate training and education
- Internal monitoring and auditing of claims
- Response and corrective action to detected deficiencies
- Enforcement of disciplinary actions
In
today's health care environment most entities are already burdened with
the every day challenge of accurate billing and coding, compliant
documentation, HIPAA, physician managed care contracts, Stark laws,
vendor contracts, and most importantly, patient service.
This leaves most health care entities with fewer resources to focus on compliance and audit issues.
With that being said, how does one go about dealing with the increased burden of potential RAC audits?
Your
initial step should be to perform an internal audit review of your
organization's documentation and compliance procedures. We know that
based on Demonstration Project results that CMS posted that somewhere
between 70% - 75% of overpayments identified were from coding errors
and lack of documentation to support medical necessity. With that being
said it would make sense that your organization focus your attention
and resources in these areas.
For your coding accuracy and
medical necessity review, it is critical to perform a "base line
review" to evaluate your organizations compliance with the rules and
regulations. The review will help you identify deficiencies and correct
them (including issuing refunds) prior to the RAC auditors showing up.
It is also critical that you implement an education plan based on your
findings for your staff and medical providers. If your practice gets in
the habit of performing a review, identifying errors and providing
education, you will notice that your error rates will drop
significantly.
In terms of your internal review, there are many
things to consider. Does your organization have the internal expertise
to decide what areas to focus on? Will you base your efforts on the RAC
findings to direct your focus on cases to validate medical necessity
and proper coding? There are many variables that need to be
pre-determined if your organization opts to do an internal audit review.
You
will need to determine how many charts to review, whether this number
is a calculated number that is representative of your annual billings
or just a random sample. These are just a few of the questions that
will need to be answered before your organization moves forward with an
internal audit review.
One thing that every facility needs to
think about that is considering doing internal audits is that you must
be confident that your audits are being performed by individuals who
are "independent". In addition it is critical that your audit team have
the appropriate skill set and credentials to be conducting the audits.
For those that do not have the resources to conduct audits internally,
consideration should be given to hiring a third party audit firm
that has the experience and credentials to assist your organization
with the internal audit function. When selecting a vendor, make sure
you are engaging a firm that has RAC experience and the appropriate
credentials of clinical auditors to ensure that they will give you the
service and skill set you need. It is critical that your audit results
can support any findings against the RAC just in case any audit issues
arise.