Surviving the RAC
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The document discusses the goals and history of the Recovery Audit Contractor (RAC) program, which aims to maximize revenue and minimize compliance costs by detecting and correcting improper Medicare payments. It provides details on RAC audits, noting that no provider is immune from review. The document recommends that providers conduct their own audits to monitor error rates, prepare a response system for RAC reviews, and consider compliance software to help reduce risks. Overall, it emphasizes the importance for providers to understand their financial risk from potential RAC audits and overpayments.
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Surviving the RAC
- 1. Surviving the RAC - kome di x increasing wealt h by managing risk
- 2. The Goal
- 4. The Goal • Hakunamattata • Maximize revenue
- 5. The Goal • Hakunamattata • Maximize revenue • Minimize compliance costs
- 6. History - kome di x increasing wealt h by managing risk
- 7. History 2003 ‣ Detect ‣ Correct ‣ Collect - kome di x increasing wealt h by managing risk
- 8. History - kome di x increasing wealt h by managing risk
- 9. History 2005 ‣ 3 year demonstration ‣ 3 states ‣ $1.03 billion - kome di x increasing wealt h by managing risk
- 10. History - kome di x increasing wealt h by managing risk
- 11. History 2006 ‣ Tax Relief and Healthcare Act ‣ Nationwide RAC by 2010 - kome di x increasing wealt h by managing risk
- 12. Meet the RACs - kome di x increasing wealt h by managing risk
- 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. No Provider is Immune - kome di x increasing wealt h by managing risk
- 15. No Provider is Immune - kome di x increasing wealt h by managing risk
- 16. What Does a RAC Do? - kome di x increasing wealt h by managing risk
- 17. Automated Reviews - kome di x increasing wealt h by managing risk
- 18. Automated Reviews ‣ Data mining ‣ Primarily outpatient services ‣ No medical record review - kome di x increasing wealt h by managing risk
- 19. Complex Reviews - kome di x increasing wealt h by managing risk
- 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. CMS Focus ‣ Medical necessity ‣ Proper coding ‣ Sufficient documentation - kome di x increasing wealt h by managing risk
- 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. Post Review Notice - kome di x increasing wealt h by managing risk
- 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. 30 41 Extended Pay Recoup Pay Pay/ Recoup Extended Appeal Pay - kome di x increasing wealt h by managing risk
- 27. 11%! 30 41 Extended Pay Recoup Pay Pay/ Recoup Extended Appeal Pay - kome di x increasing wealt h by managing risk
- 28. The Collector - kome di x increasing wealt h by managing risk
- 29. And Then? - kome di x increasing wealt h by managing risk
- 30. And Then? The process can be repeated every 45 days....! - kome di x increasing wealt h by managing risk
- 31. Guess who’s next? - kome di x increasing wealt h by managing risk
- 32. Guess who’s next? ‣ Mic’s (Medical Integrity Contractors) ‣ Commercial carriers - kome di x increasing wealt h by managing risk
- 33. - kome di x increasing wealt h by managing risk
- 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. - kome di x increasing wealt h by managing risk
- 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. CMS Recommends - kome di x increasing wealt h by managing risk
- 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
- 40. The Compliance Review 1 Result: Direction - kome di x increasing wealt h by managing risk
- 41. The Baseline Discovery 2 Result: Clarity - kome di x increasing wealt h by managing risk
- 42. The Code Optimizer 3 Result: Confidence - kome di x increasing wealt h by managing risk
- 43. The RAC Responder 4 Result: Delivery - kome di x increasing wealt h by managing risk
- 44. - 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
- 45. - 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
- 46. - 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
- 47. - 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
- 48. - 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
- 49. - your risk? Do you know
- 50. - your risk? Do you know ‣ Sample size: over 100 audits
- 51. - your risk? Do you know ‣ Sample size: over 100 audits ‣ Average error rates: 25% - 35%
- 52. - your risk? Do you know ‣ Sample size: over 100 audits ‣ Average error rates: 25% - 35% ‣ Range: 15% - 56%
- 53. Reduce Your Risk - kome di x increasing wealt h by managing risk
- 54. 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
- 55. - kome di x increasing wealt h by managing risk
- 56. - kome di x increasing wealt h by managing risk
- 57. "....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
- 58. - kome di x increasing wealt h by managing risk http://www.komedix.net/knowledge-center/ komedix.net 210.301.0650