Tools & Technology

to Manage RAC

Effective audit management and

reporting

Session Objectives

Tips for how to handle automated reviews

Recommended RAC reporting

Top five lessons learned by Sharp HealthCare

Automated RAC Audits

According to CMS, these started many months ago, but providers seem to be seeing these just as of recent

Immediate identification is the key» RAC contractors still seem to be struggling with sending letters;

check your RAC website frequently» There are situations where you may not have received a letter

but you get the remittance (N432) indicating the recoupment

• Dollar amount at risk (Medicare original payment)

• Dollar amount of net gain/loss (difference between the Medicare original payment and any takeback/ repayment including any additional rebill)

• Type of audit (complex vs automated)

• Reason for audit, audit result

• Facility, service area distinctions

• DRG – billed, paid, revised/new

Reporting Data ElementsReporting Data Elements

Total CountTotal Count

Drill down:Physician, DRG, Aging, Audit Type, Reason

Total Amount at RiskTotal Amount at Risk

Defined as Medicare original payment amount

Alerting

Establish alerts for critical deadlines such as Medical Records in process

Med Recs In Process #

Alerting

Alerts are visual within the dashboard and e-mailed to appropriate responsible parties

Med Recs in Process #

The Alert System has analyzed your Med Recs in Process # Key Indicator and found that it meets your alert criteria for alert – Med Recs in Process # goes above 0.

This alert has the following data constraints: System=All , Facility=All , Age from Request Date=31-45 ,Patient Type=All , Account ID=All .

Med Recs in Process #

Lessons Learned Lessons Learned #1#1

Minimal data entry» Inconsistent capture of data

elements, format of account numbers

Flexibility to access all data elements

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Lessons Learned Lessons Learned #2#2

Get to know your RAC contractor» Call, communicate often» Watch the website

Lessons Learned Lessons Learned #3#3

Don’t underestimate the impact of the demand (automated) audits» Is your CDM up to date?» Billing system edits current?» CPT frequencies built cleanly and

functional

Lessons LearnedLessons Learned #4#4

Identify how you are going to scan and store your records» How are you going to capture

all images and records you actually sent?

» Are there security concerns when linking from one system to another?

» Need all related documents, both clinical and administrative, in one place

Lessons Learned Lessons Learned #5#5

Additional Development Requests from FI/MAC (pre- payment reviews) have increased considerably from two years ago» Specific targeting of services

(cataract removal)» Now capturing in RAC

tracking tool and reporting trends to RAC Committee