The National Medicare RAC Summit Washington DC March 5-6 2009 Embed the RAC Program in Your Revenue...
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The National Medicare RAC The National Medicare RAC Summit Summit Washington DC March 5-6 Washington DC March 5-6 2009 2009 Embed the RAC Program in Your Revenue Cycle Process
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Carol Richardson, MA, RHIA March Adventist Health, Inc. – Roseville, CA California, Oregon, Washington and Hawaii 17 hospitals with 2800 beds – 13 in California 110,188 admissions 392,495 emergency department visits 1,969,779 outpatient visits 22 rural health clinics 15 home care agencies Clinics and outpatient facilities Three joint venture retirement centers (with a 4 th on the way) 18,000 employees
Transcript of The National Medicare RAC Summit Washington DC March 5-6 2009 Embed the RAC Program in Your Revenue...
The National Medicare RAC Summit The National Medicare RAC Summit Washington DC March 5-6 2009Washington DC March 5-6 2009
Embed the RAC Program in Your
Revenue Cycle Process
Carol Richardson, MA, RHIA March 6 2009
Adventist Health, Inc.
Not-for-profit, faith-based health care system
headquartered in Roseville, CA, just east of Sacramento
Affiliated with the Seventh-day Adventist Church
Carol Richardson, MA, RHIA March 6 2009
Adventist Health, Inc. – Roseville, CA
California, Oregon, Washington and Hawaii
• 17 hospitals with 2800 beds – 13 in California• 110,188 admissions• 392,495 emergency department visits• 1,969,779 outpatient visits• 22 rural health clinics• 15 home care agencies• Clinics and outpatient facilities• Three joint venture retirement centers (with a 4th on the way)• 18,000 employees
Carol Richardson, MA, RHIA March 6 2009
1 Corporate Office 2 Adventist Medical Center, Portland 3 Castle Medical Center 4 Central Valley General Hospital 5 Feather River Hospital 6 Glendale Adventist Medical Center 7 Hanford Community Medical Center 8 Howard Memorial Hospital 9 Redbud Community Hospital10 St. Helena Hospital11 San Joaquin Community Hospital12 Selma Community Hospital, Inc.13 Simi Valley Hospital14 Sonora Regional Medical Center15 South Coast Medical Center16 Tillamook County General Hospital17 Ukiah Valley Medical Center18 Walla Walla General Hospital19 White Memorial Medical Center
Adventist Health Site MapAdventist Health Site Map
Carol Richardson, MA, RHIA March 6 2009
Goal #1
Standardize management of RAC correspondence and payment denials across facilities
Identification Tracking Management Resolution
Our Vision – RAC DemonstrationOur Vision – RAC Demonstration
Carol Richardson, MA, RHIA March 6 2009
Goal #2
Establish coding audit of alleged coding errors and DRG changes
Select external coding vendor to perform all audits Implement process for facilities to provide data to
vendorRAC correspondenceCoding summary/abstractPhysician coding queryMedical recordUB92
Our Vision – RAC DemonstrationOur Vision – RAC Demonstration
Carol Richardson, MA, RHIA March 6 2009
Goal #2
Establish coding audit of alleged coding errors and DRG changes
Develop communication tools for vendor, facilities and Corporate
Vendor draft rebuttal correspondence Vendor and Corporate HIM jointly review audit
findings and rebuttal decisions on weekly conference calls
Our Vision – RAC DemonstrationOur Vision – RAC Demonstration
Carol Richardson, MA, RHIA March 6 2009
Goal #3
Deliver coding education on RAC coding risk areas monthly
Vendor develop curriculum including case scenarios Coder pre- and post-testing
Track with AH/MC Strategies Learning Management System Issue certificates of attendance
Deliver seminar via WebEx Archived on Corporate HIM website on AH intranet
Our Vision – RAC DemonstrationOur Vision – RAC Demonstration
Carol Richardson, MA, RHIA March 6 2009
04/06 – DRG 397, Coagulation Disorders
05/06 – DRG 217, Wound Debridement
06/06 – DRG 416, Septicemia
07/06 – DRG 468, Operating Procedure Not Related to Diagnosis
08/06 – DRG 124, Circulation Disorder
10/06 – DRG 478, Other Vascular Procedures
11/06 – DRG 475, Respiratory Diagnosis with Ventilator Support
12/06 – DRG 148, Major Small and Large Bowel Procedures
Coder Education Seminars Coder Education Seminars 20062006
Carol Richardson, MA, RHIA March 6 2009
01/07 – DRG 76, Other Respiratory System Operating Room Procedures
01/07 – DRG 82, Respiratory Neoplasms
02/07 – DRG 141, Syncope and Collapse
03/07 – Principal Diagnoses with Complications & Comorbidities
04/07 – Principal Diagnoses with Complications & Comorbidities Case Studies
Coder Education Seminars Coder Education Seminars 20072007
Carol Richardson, MA, RHIA March 6 2009
06/07 – DRG 193, Hepatobiliary Tract Procedure
07/07 – Operative Report Coding
08/07 – DRG 144, Other Circulatory System Diagnoses with Complications and Comorbidities
09/07 – DRG 415, Infections and Parasites
11/07 – DRG 174, Gastrointestinal Hemorrhage with Complications and Comorbidities
12/07 – DRG 296, Nutritional/Miscellaneous Metabolic Disorders
Coder Education SeminarsCoder Education Seminars 20072007 (continued) (continued)
Carol Richardson, MA, RHIA March 6 2009
01/08 – MS-DRGs 190/191/192, COPD
02/08 – MS-DRGs 291/292/293, Heart Failure and Shock
03/08 – MS-DRGs 299/300/301, Peripheral Vascular Disease w CC
04/08 – MS-DRGs 579/580/581, Other Skin Subcu Tissue & Breast Procedures
05/08 – MS-DRGs 602/603, Cellulitis >17 yrs. w/o CC
06/08 – MS-DRGs 193/194/195 Simple Pneumonia & Pleurisy w/o CC
Coder Education Seminars Coder Education Seminars 20082008
Carol Richardson, MA, RHIA March 6 2009
Goal #4
Implement system-wide RAC activity reporting tool
Locate on system intranet
Provide data entry access for facility RAC Coordinators Directors, Patient Financial Services
Capture 100% of RAC correspondence
Provide view access for facility and corporate administration
Our Vision – RAC DemonstrationOur Vision – RAC Demonstration
Carol Richardson, MA, RHIA March 6 2009
Auto-populate data Enter account number, From claims file,
Medical record number DRG Discharge date Coder ID
Enter account number, From DRG tables specific to facility and year
DRG weight DRG payment
Enter account number, From remittance advice file, Date recouped Dollars recouped
Our Vision for the Data BaseOur Vision for the Data Base
Carol Richardson, MA, RHIA March 6 2009
Our Vision – RAC DemonstrationOur Vision – RAC Demonstration
Goal #4
Implement system-wide RAC activity reporting tool
Data aggregation by facility and across system
Facility Coder
Service Year Facility employee
Denial Reason Vendor
DRG Dollars Recouped
Carol Richardson, MA, RHIA March 6 2009
Carol Richardson, MA, RHIA March 6 2009
Carol Richardson, MA, RHIA March 6 2009
Carol Richardson, MA, RHIA March 6 2009
Carol Richardson, MA, RHIA March 6 2009
Enterprise Government Payer Data Base
AH RAC Tracker Refine data fields Expand reporting functionalityRetrain workforce OR?
Better mousetrapInternal IT expense to bring internal data base up
to speed vs. expense of commercial product
Taking Advantage of the RAC PauseTaking Advantage of the RAC Pause
Carol Richardson, MA, RHIA March 6 2009
Taking Advantage of the RAC PauseTaking Advantage of the RAC Pause
Roll out standard, corporate policy and process for
RAC management
Facility Revenue Cycle Committee will monitor and direct RAC activity as a standard agenda item
Facilities will adopt best practices in RAC management
Carol Richardson, MA, RHIA March 6 2009
Standard Enterprise RAC Policy Identifies key stakeholders
Chief Financial OfficerHIM DirectorPatient Financial Services DirectorCase Management DirectorAncillary Department Directors
Requires designation of Corporate & facility RAC Coordinators
Taking Advantage of the RAC PauseTaking Advantage of the RAC Pause
Carol Richardson, MA, RHIA March 6 2009
Standard Enterprise RAC Policy
• Requires Facility & Corporate Revenue Cycle Committees to oversee RAC process
• RAC data base
• Correspondence, rebuttal and appeal workflow
• Denial-type action plans
• Staff education
• State/Regional hospital association RAC user groups
Taking Advantage of the RAC PauseTaking Advantage of the RAC Pause
Carol Richardson, MA, RHIA March 6 2009
Facility Revenue Cycle
Committee
HIM Director
Corporate RAC
Coordinator
Corporate Revenue Cycle
Committee
Facility RAC
Coordinator
PFS Director
CaseManagement
Director
ChiefFinancial
Officer
AncillaryDepartment
Directors
Enterprise Govt Payer Audit
Data Base
Carol Richardson, MA, RHIA March 6 2009
Talk to Providers in the Demonstration Project Vendors and consultants know some things, but not all things
Do your homework “The Medicare Recovery Audit Contractor (RAC) Program – An Evaluation
of the 3-Year Demonstration – June 2008” http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf
“Statement of Work for the Recovery Audit Contractor Program November 7, 2007” https://www.fbo.gov/download/f8f/f8f1d845d960c3229301aeec334c7eb4/2_J-1RACSOW11-5-07VS2(3).doc
RAC Best PracticesRAC Best Practices
Carol Richardson, MA, RHIA March 6 2009
RAC Best PracticesRAC Best Practices
Budget for RAC management FTE
Outsourced Coding and Medical Necessity review
Coder and Case Management education
Adequate Release of Information manhours in HIM
Counsel support in Formal Medicare Appeal Process
Carol Richardson, MA, RHIA March 6 2009
Re-Evaluate your Release of Information Solution How tight is the current turnaround? What accuracy rate is reported by your Quality Control
process? Internal vs. Outsourced?
If you outsource, consider a penalty against the invoice for any late or inaccurate RAC response
If you’re considering outsourcing, some vendors are able to incorporate document imaging which supports the rebuttal and appeal process
Track every piece of RAC Correspondence
Name and empower the RAC Coordinator position
Direct Revenue Cycle Committee to monitor RAC activity
RAC Best PracticesRAC Best Practices
Carol Richardson, MA, RHIA March 6 2009
RAC Best PracticesRAC Best Practices Require all Coders to be Credentialed
Outsource Coding and Case Management audit
Tighten Up Coding Vendor Contracts Add penalty against invoice for retroactive payment denials
Tighten Up & Expand Physician Coding Query Process
Require that physicians be queried per AHIMA guidelines Track and monitor query trends by physician, code/DRG
and coder Add pending queries to Medical Staff Bylaws, Rules and
Regulations definition of incomplete/delinquent medical record
Carol Richardson, MA, RHIA March 6 2009
Meet every deadline - NO TECHNICAL DENIALS!
Send ALL the RIGHT stuff the FIRST time
Hold the RAC accountable
ProcessesTimelines as defined by CMSCommunication
RAC Best PracticesRAC Best Practices
Carol Richardson, MA, RHIA March 6 2009
RAC Best PracticesRAC Best Practices
Rebut initial RAC decisions as appropriate
Pursue formal Medicare appeals as appropriate
Educate CodersCase Managers/Utilization Review
Network with and through hospital association
Carol Richardson, MA, RHIA March 6 2009
Carol Richardson, MA, RHIA
Corporate Director, Health Information ManagementAdventist Health, Inc.
2100 Douglas BoulevardRoseville, California 95661
