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2011 Medical Professional Liability Symposium Chicago, IL ~ March 24 & 25, 2011 THE WRECK OF THE RAC: LESSONS LEARNED FOR ALL.

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Presentation on theme: "2011 Medical Professional Liability Symposium Chicago, IL ~ March 24 & 25, 2011 THE WRECK OF THE RAC: LESSONS LEARNED FOR ALL."— Presentation transcript:

1 2011 Medical Professional Liability Symposium Chicago, IL ~ March 24 & 25, 2011 THE WRECK OF THE RAC: LESSONS LEARNED FOR ALL

2 Moderator: Fay A. Rozovsky, JD, MPH, DFASHRM, President, The Rozovsky Group Panelists: Elizabeth Baskett, MPA, Senior Associate Director for Policy, American Hospital Association Patrick J. Hurd, Esq., Senior Counsel, LeClair Ryan Alice Johansson, Senior Vice President, Product Manager, Managed Care, IronShore

3 RAC 101 The Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) permanent program was implemented for Medicare parts A & B nationwide on January 1, RACs conduct post-payment audits of Medicare Parts A & B claims. There are four RAC regions nationwide, with four separate RACs operating in each region of the country. The Affordable Care Act of 2010 expanded the RAC program to Medicare Parts C & D and to Medicaid. Implementation of Medicare Parts C & D and Medicaid RACs has been delayed until later this year. Although extremely similar, RACs are not to be confused with other payment integrity auditing programs such as the MACs, ZPICs, CERT, DOJ, etc.

4 RACs Identify Hospital Billing Mistakes RACs are not fraud busters, they audit hospitals to find billing mistakes Improper payments include:  incorrect payment amounts;  incorrectly coded services (including Medicare Severity diagnosis- related group (MS-DRG) miscoding;  non-covered services (including services that are not reasonable and necessary); and  duplicate services. RACs conduct two types of audits:  Automated reviews—using computer software to detect improper payments.  Complex reviews—using human review of medical records and other medical documentation.

5 Hospitals Nationwide Are Experiencing RAC Audits Percent Reporting RAC Activity vs. No RAC Activity by Type of Participating Hospital, through 4 th Quarter 2010 Source: AHA. (February 2011). RACTrac Survey. AHA analysis of survey data collected from 1,852 hospitals reporting RAC activity. 1,454 reporting activity, 398 reporting no activity through December Full report accessible at:

6 Hospitals Nationwide Are Experiencing RAC Denials Dollar Value of Automated and Complex Denials by RAC Region for Reporting Hospitals, through 4 th Quarter 2010, Millions Source: AHA. (February 2011). RACTrac Survey. AHA analysis of survey data collected from 1,852 hospitals reporting RAC activity. 1,454 reporting activity, 398 reporting no activity through December Full report accessible at:

7 RAC Process for Complex Review Hospitals are required to send RACs medical records upon request. RACs have 60 days to review the record and send a review results letter to hospitals. If a RAC determines an improper payment was made, the RAC will send a demand letter to the hospital indicating the amount of Medicare payment they intend to recoup. The hospital can either allow the recoupment or appeal the RAC decision using the regular Medicare appeals process. The appeals process is lengthy and administratively burdensome. Not all inappropriate RAC decisions are appealed. AHA RACTrac survey of 1,854 hospitals indicates that 23% of hospitals appealed at least one RAC decision and the RAC decision was overturned 86% of the time.

8 The Wreck of RACs Underwriter’s erspective Regulatory Coverage  Back in the day vs.  Today

9 The Wreck of RACs Underwriter’s Perspective Is a RAC audit an underwriting ‘red flag’?  Does it necessarily mean that the organization has done something wrong/bad? Geography Type of organizations/patients Types of errors Changing landscape

10 The Wreck of RACs Underwriter’s Perspective Questions your underwriter may ask  What is your organization doing to minimize the likelihood of a RAC audit?  What sorts of plans does your organization have in place to respond to a RAC audit?  What financial resources does your organization have should a RAC audit result in a significant settlement?

11 The Wreck of RACs Underwriter’s Perspective Is there insurance available for RAC audits?  D&O policy regulatory sublimits  Defense policies for small organizations  Option Agreement

12 Strategies to Reduce RACs Risks - I Education For All Education For All Implement Sound Business Practices Implement Sound Business Practices Clinical Personnel Medical Staff Coding Billing Compliance Internal Audit External Audit Coding & Billing The “answer” person “It is better to ask than be sorry” Verification process Solid documentation

13 Strategies to Reduce RACs Risks - II Homage to the Internal Audit Team! …and The RACs/PI Rounding Team. Analyzing Counseling Improving Documentation Practices

14 Strategies to Reduce RACs Risks - III Identify High Risk (Cost) Procedures Loss Prevention (Education) Loss Prevention (Education) Surveillance & Monitoring ERM Style Data Correlation ERM Style Data Correlation Evaluate Prompt Action Take a systems approach to RACs Risks

15 Strategies to Reduce RACs Risks - IV Documentation Substantiate billing/coding Correlation to Med Mal Correlation to Compliance Issues Defensible? Preempt Adverse Publicity Lessons Learned Use Good Risk Management Skills

16 QUESTIONS?

17 THE WRECK OF THE RAC: LESSONS LEARNED FOR ALL Moderator: Fay A. Rozovsky, JD, MPH, DFASHRM, President, The Rozovsky Group Panelists: Elizabeth Baskett, MPA, Senior Associate Director for Policy, American Hospital Association Patrick J. Hurd, Esq., Senior Counsel, LeClair Ryan Alice Johansson, Senior Vice President, Product Manager, Managed Care, IronShore


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