Surviving the RAC

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  • Surviving the RAC

    1. 1. Surviving the RAC - kome di x increasing wealt h by managing risk
    2. 2. The Goal
    3. 3. The Goal • Hakunamattata
    4. 4. The Goal • Hakunamattata • Maximize revenue
    5. 5. The Goal • Hakunamattata • Maximize revenue • Minimize compliance costs
    6. 6. History - kome di x increasing wealt h by managing risk
    7. 7. History 2003 ‣ Detect ‣ Correct ‣ Collect - kome di x increasing wealt h by managing risk
    8. 8. History - kome di x increasing wealt h by managing risk
    9. 9. History 2005 ‣ 3 year demonstration ‣ 3 states ‣ $1.03 billion - kome di x increasing wealt h by managing risk
    10. 10. History - kome di x increasing wealt h by managing risk
    11. 11. History 2006 ‣ Tax Relief and Healthcare Act ‣ Nationwide RAC by 2010 - kome di x increasing wealt h by managing risk
    12. 12. Meet the RACs - kome di x increasing wealt h by managing risk
    13. 13. Meet the RACs HealthDataInsights Inc. Diversified Collection Services CGI Technologies and Solutions Connolly Consulting Inc. - kome di x increasing wealt h by managing risk
    14. 14. No Provider is Immune - kome di x increasing wealt h by managing risk
    15. 15. No Provider is Immune - kome di x increasing wealt h by managing risk
    16. 16. What Does a RAC Do? - kome di x increasing wealt h by managing risk
    17. 17. Automated Reviews - kome di x increasing wealt h by managing risk
    18. 18. Automated Reviews ‣ Data mining ‣ Primarily outpatient services ‣ No medical record review - kome di x increasing wealt h by managing risk
    19. 19. Complex Reviews - kome di x increasing wealt h by managing risk
    20. 20. Complex Reviews ‣ Medical record requests ‣ 45 days to submit charts ‣ waive right to appeal if late - kome di x increasing wealt h by managing risk
    21. 21. CMS Focus ‣ Medical necessity ‣ Proper coding ‣ Sufficient documentation - kome di x increasing wealt h by managing risk
    22. 22. 2009 Records Limits
    23. 23. 2009 Records Limits ‣ Sole Practitioner ‣ 10 per 45 days per NPI ‣ Partnership 2-5 individuals ‣ 20 per 45 days per NPI ‣ Large Group 16+ individuals ‣ 50 per 45 days per NPI
    24. 24. Post Review Notice - kome di x increasing wealt h by managing risk
    25. 25. Post Review Notice ‣ Decision sent within 60 days of receipt ‣ “Demand Letters” sent with reason for determination ‣ RAC advises of right of appeal ‣ RAC will not assist with the appeals process - kome di x increasing wealt h by managing risk
    26. 26. 30 41 Extended Pay Recoup Pay Pay/ Recoup Extended Appeal Pay - kome di x increasing wealt h by managing risk
    27. 27. 11%! 30 41 Extended Pay Recoup Pay Pay/ Recoup Extended Appeal Pay - kome di x increasing wealt h by managing risk
    28. 28. The Collector - kome di x increasing wealt h by managing risk
    29. 29. And Then? - kome di x increasing wealt h by managing risk
    30. 30. And Then? The process can be repeated every 45 days....! - kome di x increasing wealt h by managing risk
    31. 31. Guess who’s next? - kome di x increasing wealt h by managing risk
    32. 32. Guess who’s next? ‣ Mic’s (Medical Integrity Contractors) ‣ Commercial carriers - kome di x increasing wealt h by managing risk
    33. 33. - kome di x increasing wealt h by managing risk
    34. 34. An investment in compliance oversight is like homeowners insurance. The risk it may be needed could be low, but going without could be catastrophic. - kome di x increasing wealt h by managing risk
    35. 35. - kome di x increasing wealt h by managing risk
    36. 36. "....the cost to the practice  of retrieving the corresponding record and forwarding the information could be 10X the amount (of overpayments).... "   American Medical Newsamednews.com   (7/08)  - kome di x increasing wealt h by managing risk
    37. 37. CMS Recommends - kome di x increasing wealt h by managing risk
    38. 38. CMS Recommends ‣ Conduct audits ‣ Determine and monitor your error rate ‣ Stay current with RAC issues ‣ Prepare response system - kome di x increasing wealt h by managing risk
    39. 39. The Compliance Review 1 Result: Direction - kome di x increasing wealt h by managing risk
    40. 40. The Baseline Discovery 2 Result: Clarity - kome di x increasing wealt h by managing risk
    41. 41. The Code Optimizer 3 Result: Confidence - kome di x increasing wealt h by managing risk
    42. 42. The RAC Responder 4 Result: Delivery - kome di x increasing wealt h by managing risk
    43. 43. - your risk know RAC Calculator ™ Billings x Error Rate x Time (yrs) = Total ÷ 220 Per Diem - kome di x increasing wealt h by managing risk
    44. 44. - your risk know RAC Calculator ™ Billings $300,000 x Error Rate x Time (yrs) = Total ÷ 220 Per Diem - kome di x increasing wealt h by managing risk
    45. 45. - your risk know RAC Calculator ™ Billings $300,000 x Error Rate 25% x Time (yrs) = Total ÷ 220 Per Diem - kome di x increasing wealt h by managing risk
    46. 46. - your risk know RAC Calculator ™ Billings $300,000 x Error Rate 25% x Time (yrs) 3 = Total ÷ 220 Per Diem - kome di x increasing wealt h by managing risk
    47. 47. - your risk know RAC Calculator ™ Billings $300,000 x Error Rate 25% x Time (yrs) 3 = Total $225,000 ÷ 220 Per Diem - kome di x increasing wealt h by managing risk
    48. 48. - your risk? Do you know
    49. 49. - your risk? Do you know ‣ Sample size: over 100 audits
    50. 50. - your risk? Do you know ‣ Sample size: over 100 audits ‣ Average error rates: 25% - 35%
    51. 51. - your risk? Do you know ‣ Sample size: over 100 audits ‣ Average error rates: 25% - 35% ‣ Range: 15% - 56%
    52. 52. Reduce Your Risk - kome di x increasing wealt h by managing risk
    53. 53. Reduce Your Risk Error Rate with DRP Potential Risk $ Time without DRP with DRP Potential Risk $ - kome di x increasing wealt h by managing risk
    54. 54. - kome di x increasing wealt h by managing risk
    55. 55. - kome di x increasing wealt h by managing risk
    56. 56. "....it is more cost-efficient to be proactive in developing an effective compliance program than responding to a compliance request without having adequate compliance processes in place." Patient Protection and Affordable Care Act - kome di x increasing wealt h by managing risk
    57. 57. - kome di x increasing wealt h by managing risk http://www.komedix.net/knowledge-center/ komedix.net 210.301.0650

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