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A couple of things that I think I’ve learned this year are these:



  • We need to be more proactive;
  • We need to utilize targets and findings as a learning process; and
  • The model of our RAC committee can be modified into being about more than just RACs: it can evolve into being a regulatory audit committee in its own right, addressing not only RACs, but CERT (Comprehensive Error Rate Testing), ZPICs (Zone Program Integrity Contractors), MICs (Medicaid Integrity Contractors) and other investigations.



I often ask my staff and myself, “if you were a RAC, what targets would you focus on, and where would you do some data mining?” I also ask where there are underpayments —  services that we rightfully should or could have been paid for, but weren’t – and why weren’t we paid for them?


Proactive, Not Reactive


This leads to knowing how to be proactive, rather than reactive, in the environment of RACs. By definition, being proactive is acting in advance to deal with an
expected difficulty; it’s being anticipatory. We all are aware of many areas that need improvement. We all have had audits conducted, heard from our staff and received denials, and thus we know where there are weaknesses and vulnerabilities to which we can respond.


With a compliance and/or RAC committee in place, we should have a list of risk areas that demand our attention. This can be a powerful tool and provide a means for us to develop strategies that include having a proactive compliance or RAC plan in place.


Another way to be proactive is by checking your RAC’s website a couple times a week: this is important to do. The mail doesn’t always get delivered in a timely manner, and we need to know about requests as soon as possible – and in this respect, the websites might be our best source. Still, ask if there are issues with the internal mail delivery at your hospital or practice, as this can create issues with timeliness.


Identify Gaps


Monitoring your internal mail dissemination, identifying where there are gaps and fixing them – -not just complaining about them – -also is a way of being proactive. Auditing for admitting physician orders and compliance with medical necessity is a mainstay of compliance and a RAC defense. This could mean auditing or monitoring case management or utilization review and the criteria being used to validate medical necessity of your hospitalized patients.


Be sure to have continuing audits, plus corrective action plans with timelines and education in place, as these are just a few key steps to diminishing incorrect documentation, coding and billing (which equates to overall risk).


Other areas that we need to look at are outpatient wound care documentation and coding; interventional and cardiac interventional radiology documentation and CPT® coding; the practice of auto-charging via CDM (Charge Description Master) without documentation linkage; and professional fee coding compared to hospital coding for the same encounters/services.


Identify Underpayments


Some underpayment areas also should be looked at, and these might include inpatient patient status codes (discharge disposition); missed CC/MCC (comorbidities/complications and major comorbidities/complications); and HCCs (Hierarchical Conditions Categories – Part C).


The utilization of the electronic health record to improve documentation, clinical documentation improvement and the use of computer-assisted coding (CAC) technology may provide some answers and solutions to the above.


Not One, But All RACs


Learn from the current targets not only of the RAC in your region, but also those of other RACs. Is your compliance or RAC committee reviewing the published targets for all of the contractors? Review the RAC websites regularly, read articles and expand your knowledge of the national RAC scene. This can be very helpful, and might be something to include in the meeting agenda for 2011.


We now know that nearly all DRGs are listed as potential risks, so this means that both medical necessity and coding need greater oversight, auditing, education and monitoring. We also need to look over the published plans for future regulatory audit contractor activities, as this includes scrutiny of Medicare Part C and D. What is your volume when it comes to this payer type?



Alphabet Soup of Auditing


There is an alphabet soup of auditing going on under the regulatory umbrella, including activity by CERT, MICs and ZPICs. It seems like they are coming from all directions, and as providers we need to be more aware of their work, even if we haven’t experienced an audit or investigation yet. Read about the regulatory audit scope of work BEFORE they come knocking at your door. Include and expand your compliance and/or RAC committee to cover these other regulatory areas, and be prepared for them.


Make sure your RAC tracking tool also covers them or that you otherwise possess the ability to monitor the activities of other regulatory auditing activities. Being aware and informed will allow for quick intervention for any unexpected occurrence or


The AHA (American Hospital Association) has a dedicated website for RACs, so check that out too. The CMS (Centers for Medicare Medicaid Services) website also can be a great source of information, so check it regularly as well. Let’s not forget the publication of the next RAC summary report by CMS, which will serve us well in our compliance, RAC, revenue cycle and operational meetings.


2010 has been a year that we can learn from as we move into 2011, so now is the time to look back, to ask what you’ve learned and to adjust your work plan with the goals and activities that will diminish financial risk.


Remember to track RAC activities and have data to analyze and compare regularly, as this will make the year ahead a little easier and manageable. Happy New Year!


About the Author


Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, is the Regional Managing Director of HIM for 21 acute-care hospitals in Northern California. She Co-chairs the regional RAC Committee with compliance.


Contact the Author




To comment on this article, please go to: editor@racmonitor.com


To read article entitled, “Compliant Coding: Take the Cheater Test,” please click here


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