RAC stands for Recovery Audit Contractor. It represents the effort to audit healthcare providers on behalf of Medicare and Medicaid to ensure that medical facilities are not overbilling—intentionally or unintentionally — and identify and correct improper payments. As many health agencies switch to a value-based payment model and the Centers for Medicare & Medicaid Services (CMS) increases its scrutiny, learning more about RAC healthcare audits has become much more urgent now than ever. Getting a RAC audit notice can spike you and your staff’s stress levels and leave you wondering what went wrong and when. The more you know about these audits, the better as it will help you deal with them, if not prevent them.
Strategies to Minimize RAC Audits/Avoid Denials
Consistency in Documentation
RACs want documentation to be consistent throughout the medical record, which is, let’s be honest, exactly what most of us in healthcare want. Nonetheless, there are inconsistencies. Sometimes, such medical records are provided where diagnoses are initially listed but they are nowhere to be seen by the time the discharge summary is dictated. There are also times when the diagnoses are only listed on certain pages and removed from the other pages in the medical record. Be careful with these mistakes as RACs closely look at these activities in order to deny them on grounds of inconsistent documentation. For healthcare facilities, they must work with their medical staff, teams involved in CDI, and HIM experts to maintain consistency in documentation — by having all possible diagnoses listed on the discharge summary, identifying cases where the diagnoses are not listed throughout the chart, and lastly, if the case is about to be finalized by your coder, holding that case for the query to prevent RAC healthcare audit denials.
Avoiding Contradictory Documentation
Contradicting documentation is one of the most common reasons for denials that RAC uses and it’s exactly what it says — diagnoses that contradict each other. Scenarios often include bacteremia and sepsis, acute renal failure and renal insufficiency, and urosepsis and sepsis. While the physician can use them interchangeably, when you look from the coding perspective, you simply cannot do that because there’s a specific code for each diagnosis. You are not allowed to have one code that covers all those diagnoses.RACs are always looking for contradictory documentation and deny both codes at the time of RAC healthcare audit. There is no denying the fact that querying the physician is a time-consuming and costly process, and sometimes, requires multiple requests to get the physician to respond, it is vital if you really want to minimize your risk in this area.
Diagnoses Should Meet Clinical Indicators
Often, the diagnoses do not meet clinical indicators. For example, infection is documented throughout the medical record; however, the clinical indicators don’t meet it. Most common examples of high-risk diagnoses that RACs targets are acute respiratory failure, pneumonia, sepsis, and congestive heart failure cases. During the RAC healthcare audit, the auditors ask coders, nurses, and physicians to identify these cases and deny them in the end from a clinical validation perspective. To avoid this mistake, the hospitals need to work together with their medical staff, clinical documentation improvement group, and coders to identify these cases. They should create a relatively more proactive approach to reduce the organization’s risk in this area. In addition to that, the hospitals should provide necessary training to their coders to look beyond the documentation and clinical indicators —and if there are inconsistencies found, query the physician at the earliest.
Select the Correct Root Operation
With ICD-10 PCS incorporation, it has become necessary that coders understand root operations for a procedure. Selecting the incorrect root operation often results in coders encrypting procedure codes, which leads to the wrong MSDRG. During RAC healthcare audits, the auditors are closely analyzing procedure codes and trying their best to identify these codes as potential overpayments. It is evident for the hospitals to continue training their coders with internal audits to help minimize these types of denials.
List and Chart One Complication or Co-Morbidity Case
This is one area where a lot of healthcare facilities are overlooking a low hanging fruit. To a patient that gets admitted to a hospital for an appendectomy, and develops an acute blood loss anemia, you would have assigned the correct code for the acute blood loss anemia. In this case, the RAC, at the time of RAC healthcare audit, wants to ensure the documentation is appropriate and valid —after reviewing the clinical indicators. Hospitals need to identify these as only one complication or co-morbidity cases and make sure that everything has been reviewed and validated —from documentation and clinical indicator perspective —to prevent a denial on this end.
Let Medlinks Cost Containment Help You Avoid Denials
Medlinks Cost Containment helps healthcare facilities prevent themselves from RACaudits which pose a serious threat to their practice, finances, and reputation. We provide you with tips, suggestions, and practical solutions on how you can avoid RAC denials, stay compliant, and improve your bottom line.