RAC Forensics 101
PART 1: MEDICAL RECORD REQUESTS AND THE DISCUSSION PERIOD
By Sharon Easterling, MHA, RHIA, CCS
THIRTEEN MONTHS AFTER the Recovery Audit Contractor (RAC) process was implemented nationwide, healthcare orga- nizations are still learning how to best manage the audit pro- cess. The initial reviews were automated, but since that time RACs have also begun complex coding reviews and medical necessity reviews. This is the first article in a series of three to discuss the RAC process from requests to appeals. The next article will discuss the provider portal, the discussion period, and review results letter. RAC Tracking
Organizations should create and implement a tool to monitor
and track the RAC process. A spreadsheet can be used, but it
may not be practical or sensible because currently there are at
least 90 data elements that are key to the process.
The ideal tracking tool has the ability to interface with hospital health information systems or the claims processor. This interface should capture more than encounter details and extend
to charge detail of units, modifiers, visit codes, and condition
codes. This level of detail is key to reducing RAC risk and implementing process change within an organization.
Unfortunately, most organizations don’t have access to this
type of system. However, many organizations have found success leveraging their IS departments to create a database using a
common program such as Microsoft Access. This allows for easy
data entry and the ability to run reports to track and trend data.
It can be very cost effective and offer the provider the ability to
capture data elements many other systems do not.
Organizations should keep in mind the volumes of information needed for the RAC reviews and determine what tool works
best for them. Remember, RACs are not the only regulatory entities organizations must contend with. Implementing one system that tracks multiple audits would be of great value from a
risk and compliance perspective.
Tracking Medical Record Requests
RACs can send only one request every 45 days. In order to stay
on top of these requests, organizations should track all RAC requests for records. There can be errors in any process so it is an
organization’s responsibility to identify inappropriate and untimely requests.
So how should an organization set up an internal system to
monitor and satisfy RAC requests? First, organizations should
know their medical record limits, which is dictated by the Centers for Medicare and Medicaid Services. This cap limits the
maximum number of records the RAC can request every 45 days
and has a maximum of 300 records for providers, with a cap of
250 for durable medical equipment suppliers. There have been
facilities receiving the maximum requests consistently since
RACs began reviewing medical necessity.
Organizations should identify their current trends for requests
to assist in making staffing adjustments for turning around requests and entering data into the tracking system. This will ensure organizations consistently address the demands of the RAC
process. It also can provide a framework to help make process
decisions related to the average number of records that can be
successfully turned around within a specified time frame.