The Centers for Medicare and Medicaid Services will fully launch its Recovery Audit Contractor (RAC) program by January 2010, and hospitals need to be ready.
Attendees at the Healthcare Financial Management Association's ANI 2009 will have an opportunity to get better prepared for RAC in sessions like "Ensuring your organization is RAC ready: high-cost, high-reimbursement cases."
Robert R. Corrato, MD, president and CEO of Executive Health Resources, anticipates that RACs and other governmental auditing programs will target high-cost, high-reimbursement cases for review.
"These types of cases are among the most common, resulting in one-day stays, so they have been a big target in the past," Corrato explained. "The paradigm that has existed where the billing status of a procedure is established by the procedure itself is no longer valid. Many procedures today can be done in either the inpatient or outpatient setting. Therefore, consideration must be given to procedure-based risk factors, severity of illness and patient risk factors when determining the appropriate procedural setting."
Thomas McCarter, MD, chief clinical officer at Executive Health Resources, said interventional cardiac procedures (ICPs) are one example of the high-cost, high-reimbursement cases that RACs have targeted in the demonstration project.
"As a result, evidence-based practices will play a crucial role in demonstrating the presence of medical necessity of any inpatient claims that are ever called into question down the line," McCarter said.
In their ANI education session, Corrato and McCarter, along with Lynn M. Leoce, corporate director of case management for Adventist Health System, will outline methods for mitigating risk and implementing proactive measures to avoid audits; walk through the top ten questions that hospital leaders need to ask to ensure appropriate inpatient/outpatient classification is occurring 100 percent of the time; and share a case study on ICPs, discussing important evidence-based review protocols.
CFOs, CEOs, compliance officers, counsel, risk managers and anyone responsible for audit and internal controls in healthcare facilities are encouraged to attend this session.