Bret Bissey

Now that we know the RACs are rolling out their reviews of claims related to medical necessity (Regions B, C and D), it is worthwhile to consider once again how individual providers will plan and react to this challenge.

One of the biggest challenges compliance professionals face is how to get the attention of their audience (board members, physicians, nurses, administrators, staff) when making others aware of the importance of the compliance programs within their institutions.

By now you probably are familiar with recently enacted provisions of the new Patient Affordable Care Act (PACA), which includes several changes to the federal False Claims Act and Anti-Kickback Statute, plus alterations of other requirements associated with timely repayments of overpayments.

If you were one of the more than 2,000 people in attendance at the Health Care Compliance Association’s annual institute in Dallas this April, you probably were impressed, as I was, with the increased focus and energy that our government and enforcement colleagues brought to the meeting. I was left with the distinct impression that compliance programs need to be in place and functioning within the organizational structure and culture of all healthcare providers.

One of the challenges currently existing within our hospitals involves sorting out all of the different priorities bidding for the attention of leadership. One challenge many leaders may be facing is "how do we keep RACs in front of everyone?"

The elements of a Model Compliance Program, as detailed to us on numerous occasions by the Department of Health and Human Services, Office of Inspector General's office, provides to healthcare providers an appropriate structure from which to prepare for RAC.

Watching how we, as humans, react to threats is a fascinating experience. For all hospitals, the threat of RAC denials of one-day and short-stay cases is real.