Deciding how your own internal processes are going to work once the RAC letters start rolling in is probably one of the most daunting tasks we all are grappling with at the moment.
Many hospitals already have mapped out their workflow and are on top of the process long before the letters are set to arrive. Part of that process is to ascertain HOW everything is going to be tracked to make sure that things are flowing in a timely manner and that nothing falls through the cracks.
A big decision in that respect is electing whether to use an automated tracking system to maintain relevant information for audits - not just RAC audits, but all the other audits coming down the pike as well. Obviously, tracking your dates and deadlines throughout the RAC process assures not only that the system moves efficiently and effectively, but that you avoid technical denials caused only by missed deadlines.
Deciding whether to use an outside vendor or create a database on your own demands a review of many factors. Your tracking tool should be able to handle information for multiple facilities and provider types (hospital, home health, physician group) and involve all of your RAC teams in the use of the system. Whichever tool you choose, the authors of the RAC Workbook (Find in RAC University Shop) recommend that the system has the capability to carry out these functions:
- Create and track multiple task assignments
- Attach electronic records and files on both the request and claim levels
- Track the accountability of each step and person throughout the system
- Send e-mail reminders of important tasks and approaching deadlines
- Provide a "belt and suspenders" approach to assuring that all bases are covered in task and deadline assignments
Also, through your audit process, you should track the following information:
Demographic data
Facility names
RAC audit request numbers
Patient account numbers
Medical record numbers
Patient names
Health insurance claim (HIC) numbers
Admission dates
Discharge dates
Total billed charges
Total originally paid
DRG/APC
Principal and secondary diagnoses
Types of service
Admitting/Attending physicians
Requests
Number of claims requested
Postal/FedEx tracking numbers
Names of auditing bodies
Dates of initial request letters
Dates initial request letters received
Confirmation that records were received by RAC
Date records sent to RAC
Number of pages sent/reconcile claims to request letter
Track copying costs vs. reimbursement
Determination
Reasons for the denials
Number of denied claims
Results of the audit
Types and trends of denials
Date review results letter sent and received
Date demand letters sent and received
Recoupment
Dates of reimbursement or recoupment by CMS
Amounts of reimbursement or recoupment
Appeals
Data to decide whether to launch a discussion period
Data to decide whether to launch an appeal (and, if so, at what level)
For each appeal level:
- Status of every appeal
- Basis of appeal
- Date appeal letter sent from facility
- Appeal due date
- Date appeal decision due back from RAC
- Date appeal determination received
- Appeal outcome (upheld or overturned)
- Whether to move to the next level of appeal
Additionally, it is vital that a number of these following elements also exist within the reporting tool to ensure that the workflow is indeed flowing!
Attachments
Attach copies of medical records, correspondence, and appeals directly to the claim
Communication
All verbal and written communication (calls, e-mail, any correspondence), performed both internally and between the facility and the auditor
Tasks
Who is responsible for what, and when is it due?
Make sure task assignments are communicated quickly to those responsible for completing them, and that management is kept informed
Timelines
What is soon due and when?
How can I manage my team and keep them informed that big work demands are coming up?
Financial impact and risk to the organization
Reports that indicate at-risk dollars in each level and corresponding statuses
Trending and analysis that shows patterns, both with providers and RACs
Compliance
Indicators of reportable events
Broader compliance issues that need further investigation and auditing
Duplicate claims
Are you tracking duplicate claims to ensure that another auditing body hasn't already reviewed this claim?
Other audit types
Are you tracking other types of audits? MICs? ZPICs, QIOs, MACs, CERT, etc.
If you cover these bases with any tracking tool, you can be assured that you have a strong chance of exercising your right to work through the appeal process.
Those of us who have tried to manage with a spreadsheet or an Access database can offer some advice to those of you who are considering this option - DON'T! Your return on your investment is immediate and powerful with an automated option that ultimately provides many tools in your RAC tool belt.
Carla Engle blogs regularly at RACMonitor.com.