If the Recovery Audit Contractor comes calling, your financial data will be put to the test. The good news: There are a number of measures that can stave off unwanted discoveries.
Carla Engle, a product manager at MediRegs, a division of Wolters Kluwer, offers 10 steps providers can take to make themselves more audit-proof.
- Automated tracking tools – Engle recommends getting a claims tracking mechanism in place if you don’t already have one. Software programs will track claims information including due dates for necessary claims steps, track trends and store data including patient records and correspondence from the auditor. A good tracking system can help cases from falling between the cracks, she says.
- Clinical Documentation Integrity program – Also known as Clinical Documentation Improvement programs, these service programs teach doctors and other clinicians how to be better at case documentation. Engle says an in-house program might include shadowing clinicians, concurrent coding and issuing "report cards." This is particularly helpful for physicians in high-risk areas, she says.
- Data mining – This is an internal auditing system that checks for vulnerabilities, or, as Engel says, "hot-button issues." Examples of two hot-button issues are DRG validations and Medically Unlikely Edits (MUEs.) Engle says DRG validations, examined in complex audits that include reviewing records, are high-volume, high-dollar reimbursements and high-discharge volumes. MUEs, which do not require reviews of records, look for units of service that are in excess of the maximum expected for a particular CPT code for a beneficiary on the same day of service.
- Staffing – Look ahead to potential staffing needs in the event of a RAC audit. Staff will be needed for case management and possibly for legal assistance if any RAC decisions will be appealed. Outsourcing may be necessary.
- Costs – Organizations need to consider what costs are at risk – as Engle says, the hard and soft dollars. The hard dollars are claims at risk, while the soft dollars are the administrative costs incurred during the process. Engle says the estimated cost of each appeal is $2,000 to $5,000.
- Communicate internally – Providers hurt themselves when communications between departments break down, and when people blame each other for events. Engle says one benefit of being proactive about audits is creating a team mentality.
- Communicate with the RAC auditor – "I've found most of the RACs to be approachable," Engle says. Keep in regular communication and document those interactions, she says. Also keep track of the RAC people you interact with, to make sure they are not missing pieces of communication between them.
- Look ahead to the appeals process – Engle advises developing an appeals strategy that includes delegating responsibilities and having a plan, should an appeal be necessary. First, it's necessary to know whether an appeal will proceed if a denial is given – establish a dollar threshold on claims that will be pursued. Then identify who will be responsible, and determine when you will exercise your discussion period, an informal process that allows the provider to discuss the case with the auditor, and perhaps avert an appeal by providing more information.
- Foresee criminal charges – Be aware that referrals can be made by RAC auditors to the OIG-HHS (Office of Inspector General, Health and Human Services), the law enforcement arm of the Department of Health and Human Services. OIG investigates and prosecutes cases of fraud and abuse.
- Use the RAC to keep you on your toes – Engle recommends making yourself audit-ready in general, because the RAC is not the only outfit checking Medicare claims. Be aware of other auditors such as MACs, ZPICs and Prepayment Reviews. Other payers may also audit, as well as auditing bodies such as MICs and MFCU.