Preparing Your Practice For The Medicare Rac Audits
Due to the success of the Recovery Procession Contractor ( RAC ) expo, CMS rolled out the Medicare RAC audits to all states in the year 2010 with the anticipation of recouping more monies and returning the improperly paid claims to the Medicare Hope Loot.
The program has been consistent a success that Medicaid has jumped on the band wagon and has mandated a homogeneous program known as the Medicaid Forthrightness Contractor ( MIC ), which will be implemented in all 50 states by the year 2011
Now is the time to prepare for larger scrutiny of your claims by civic agencies as its no longer a matter of will you be audited but when you will be audited.
The Department of Health and Human Services and Office of Conciliator General provides a model formal compliance program to dispense healthcare providers with guidance to on how to be compliant with CMS rules and regulations and to reduce a healthcare organizations risk exposure if they were subjected to an insurance analysis. The seven elements of a model compliance program per the OIG are as follows:
Designation of a compliance commander and compliance committee
Development of compliance policies and procedures
Establishment of open produce of communication
Appropriate training and education
Internal monitoring and auditing of claims
Response and corrective movement to detected deficiencies
Enforcement of disciplinary actions
In today ' s health care environment most entities are started hopeless with the everyday challenge of accurate billing and coding, compliant document, HIPAA regulations, physician managed care contracts, Capable laws, vendor contracts, and most importantly, patient service.
This leaves most health care entities with limited resources to focus on compliance and second thought risk issues.
With that being uttered, how does a healthcare organization, regardless of size, go about dealing with the further burden of abeyant insurance report scrutiny from both national and commercial payer?
The first step should be to perform an independent internal survey review of your organization ' s docket and compliance procedures. We know that during CMSs three year RAC Revision Frame up Project, their findings indicated that climactically between 70 % - 75 % of the overpayments identified were from coding errors and lack of tab to support medical necessity. It would make sense that a healthcare organizations focus should be on ensuring that their providers are utilizing proper coding and supporting it with the correct docket and that medical necessity is remarkably documented for each patient encounter that supports the services rendered and billed.
To dispose the exactness of your providers coding and label and proper medical adjudication making, it is critical that your organization conduct on - animation internal audits to conclude any deficiencies that may obtain within your organization. The review will help you spot deficiencies and avow you to correct them through proper education and training for your providers, which in turn will reduce your inspection risk significantly if you are faced with an insurance procession. Implementing an education and training program based on your findings for your mace and medical providers is an factual as you will attention that once implemented, your mistake rates useful to coding and certificate deficiencies will drop significantly.
If commensurate deficiencies are not identified and addressed by your organization, you may find Medicare or Medicaid knocking at your splash door to blab you of your privation of compliance. At this point, the cost of disputing or paying for the findings of a national another look will broad outweigh the cost of your organization identifying these issues first and putting a support power plan in whereabouts to terminate them.
In terms of your national review, there are many things to consider. Does your organization have the national talent to conduct proper audits and decide what areas to focus on? Will you maleficent your efforts on the Medicare RAC findings which consist of validating that medical shortcoming is properly documented and that the coding that was billed is supported by proper documentation in the patient inroad notes? There are many variables that need to be pre - tenacious if your organization opts to do an internal view review.
One thing every facility should see about that is considering conducting internal audits is that you must be confident that your audits are being performed by individuals who are " independent " of the document they are reviewing. It is also critical that your check team have the just skill set, credentials and rainless understanding of the compliance rules and regulations per the Centers for Medicare and Medicaid Services ( CMS ) to be conducting the audits. If your organization lacks these resources, serious consideration should be given to hiring a third party inspection firm that has the experience and credentials to assist your organization with the internal scan function. When selecting a vendor, make complete you are engaging a firm that has civic reconsideration experience and that they can name any compliance deficiencies and more importantly, line your personnel with the proper training and education to eliminate consistent deficiencies. The cost of utilizing a third party to assist your organization
will dramatically reduce your inherent march past risk and your return on your investment will be tenfold compared to what the financial consequences could potentially be if you sit back and do nullity and let Medicare be the messenger.
