Preparing Your Practice For The Medicare Rac Audits
Due to the success of the Recovery View Contractor ( RAC ) array, CMS rolled out the Medicare RAC audits to all states in the year 2010 with the anticipation of recouping more monies and returning the improperly paid claims to the Medicare Hope Riches.
The program has been equaling a success that Medicaid has jumped on the band wagon and has mandated a parallel program known as the Medicaid Integrity Contractor ( MIC ), which will be implemented in all 50 states by the year 2011
Now is the time to prepare for new scrutiny of your claims by state agencies as its no longer a matter of will you be audited but when you will be audited.
The Department of Health and Human Services and Office of Arbiter General provides a model formal compliance program to administer healthcare providers with guidance to on how to be compliant with CMS rules and regulations and to reduce a healthcare organizations risk exposure if they were subjected to an insurance check. The seven elements of a model compliance program per the OIG are as follows:
Designation of a compliance eminence and compliance committee
Development of compliance policies and procedures
Establishment of open wares of communication
Appropriate training and education
Internal monitoring and auditing of claims
Response and corrective reaction to detected deficiencies
Enforcement of disciplinary actions
In today ' s health care environment most entities are commenced inappropriate with the everyday challenge of accurate billing and coding, compliant ticket, HIPAA regulations, physician managed care contracts, Heavy-duty laws, vendor contracts, and most importantly, patient service.
This leaves most health care entities with insufficient resources to focus on compliance and file risk issues.
With that being oral, how does a healthcare organization, regardless of size, go about dealing with the expanded burden of future insurance once-over scrutiny from both national and commercial payer?
The first step should be to perform an independent internal drill review of your organization ' s label and compliance procedures. We know that during CMSs three year RAC Column Spectacle Project, their findings indicated that hereafter between 70 % - 75 % of the overpayments identified were from coding errors and need of label to support medical necessity. It would make sense that a healthcare organizations focus should be on ensuring that their providers are utilizing proper coding and supporting it with the correct docket and that medical necessity is distinctly documented for each patient encounter that supports the services rendered and billed.
To finish the exactness of your providers coding and mark and proper medical resolution making, it is critical that your organization conduct on - functioning internal audits to rule any deficiencies that may materialize within your organization. The review will help you name deficiencies and let on you to correct them through proper education and training for your providers, which in turn will reduce your display risk significantly if you are faced with an insurance report. Implementing an education and training program based on your findings for your mace and medical providers is an existent as you will notice that once implemented, your oversight rates opportune to coding and tab deficiencies will drop significantly.
If consistent deficiencies are not identified and addressed by your organization, you may find Medicare or Medicaid knocking at your array door to let on you of your want of compliance. At this point, the cost of disputing or paying for the findings of a public view will inmost outweigh the cost of your organization identifying these issues first and putting a advice work plan in domicile to wrap up them.
In terms of your inland review, there are many things to consider. Does your organization have the at rest talent to conduct proper audits and decide what areas to focus on? Will you vicious your efforts on the Medicare RAC findings which consist of validating that medical dearth is properly documented and that the coding that was billed is supported by proper ticket in the patient intervention notes? There are many variables that need to be pre - dogged if your organization opts to do an internal view review.
One thing every facility should plan for about that is considering conducting internal audits is that you must be confident that your audits are being performed by individuals who are " independent " of the docket they are reviewing. It is also critical that your recapitulation team have the rightful skill set, credentials and crystal understanding of the compliance rules and regulations per the Centers for Medicare and Medicaid Services ( CMS ) to be conducting the audits. If your organization lacks these resources, serious consideration should be accustomed to hiring a third party scrutiny firm that has the experience and credentials to assist your organization with the internal another look function. When selecting a vendor, make irrefutable you are engaging a firm that has state reflection experience and that they can distinguish any compliance deficiencies and more importantly, render your personnel with the proper training and education to eliminate like deficiencies. The cost of utilizing a third party to assist your organization
will dramatically reduce your potential march past risk and your return on your investment will be tenfold compared to what the financial consequences could potentially be if you sit back and do zippo and let Medicare be the messenger.
