Nancy Hirschl, CCS	Lori Brocato

Welcome to the last edition of RAC Ready.  We hope you found the past year of Web columns informative and helpful as you worked to prepare for the recovery auditor contractor (RAC) audits. As 2009 comes to a close, we wanted to review three important lessons we learned, share the latest developments with the RAC program, and round-up five tips for your continued RAC success.

Lessons Learned in 2009
This time last year we were waiting for contractor protests to be resolved. Today we await the Centers for Medicare and Medicaid Services' (CMS) final approval for complex reviews for the RACs. Waiting seems to be a recurring theme when it comes to the recovery audit program. Despite the delays, recovery audit reviews are here to stay and are predicted to expand into Medicaid and other third-party payers in 2010. With that in mind, let's quickly review the top three lessons learned this year.

Lesson #1: Nothing Ever Starts on Time With the U.S. Government
Health care reform. Meaningful use. Recovery audit contractor programs. It seems like governmental delays were the norm in 2009. But just because RAC audits didn't start on time in 2009 and activity for automated reviews was minimal, recovery audits aren't going away. In fact, they are here to stay.

The CMS is taking a lot longer than expected to approve complex reviews with only one region, Region C, just recently announcing CMS-approved audit issues. Providers in Region C should check the Connolly Web site for more information, ensure your contact information is correct with Connolly (who should receive request letters), and review Connolly instructions and timelines. Visit HealthPort to learn more about the 24 issues that include many of the same issues reviewed in the demonstration project.

Look for 2010 to be the "year of the audit" as complex reviews begin and HIM professionals get fully engaged.

Lesson #2: Medical Necessity Is the Secret Sauce
At my local Chinese restaurant, secret sauce turns a daily lunch special into a divine delight. Meeting medical necessity is the RAC secret sauce to reduce Medicare take-backs and minimize complex reviews. The most important lesson learned in 2009 is that where medical necessity is concerned; burying your head in the sand is NOT a strategy! Common sense must prevail.

Medical necessity reviews by the RACs will focus in the same areas as demonstration project reviews. These are the areas where RACs discovered the majority of Medicare take-backs; found the most money.

• Short stay patients

Evidence-based care guidelines such as Milliman or McKesson's InterQual Level of Care criteria should be completed by case managers based on physician documentation. Both parties must be apprised of the RAC risk: case managers and medical staff.

• Inappropriate inpatient surgical procedures

Inpatient surgery cases that could have been done as outpatient procedures are also at high risk for RAC take-backs. These cases must have significant clinical documentation to justify inpatient status. Now is the time to conduct clinical documentation audits and begin educating medical staff.

Lesson #3: Never Underestimate the Importance of Physician Documentation
RACs have become the catalyst for performance improvement in clinical documentation for physicians, case managers and coders. The challenge for HIM is the same as it has been for years; how to get buy-in from physicians who have little or no financial impact from a negative RAC decision-at least not yet. Furthermore, HIM must learn how to bring case managers and coders together into a single, cohesive team to work with the physicians on documentation improvement initiatives.

Some hospitals have decided to do nothing until RAC complex reviews begin and denials emerge. As mentioned above, we strongly recommend against this type of a wait-and-see strategy; it only results in additional work and greater risk. Strong clinical documentation improvement programs must be in place now to prepare for what's ahead in 2010.

Now it's time to set expectations for 2010.

Gearing Up for 2010
While no one can completely predict what will happen with RAC in 2010 and which trends will emerge, a few practical tips for HIM professionals apply:

1.      Brace for the same types of issues and cases seen in the demonstration project.

2.      The appeal process will be different and record request limits have changed. Additional Documentation Request (ADR) limits were just announced by CMS on Dec. 2, 2009. Visit HealthPort to understand how these new limits will impact your release-of-information staffing and RAC process.

3.      There will be added focus on outpatient treatments, especially those for chemotherapy and ambulatory infusions. HIM professionals should ensure correct billing was performed, audit nursing documentation (documentation must support codes and bills assigned), and work closely with individual clinical departments, nursing leads and charge entry staff.

4.      Continue to hold RAC team meetings and include a representative from the aforementioned outpatient areas.

5.      Understand and be prepared for expansion of recovery audits into Medicaid (MICs) and other third-party payers. Establish new audit teams or expand the responsibilities of your current RAC team in 2010 to accommodate.

RAC: An Opportunity for HIM to Shine
In January 2009, we encouraged HIM professionals to get fully immersed in RAC. We're repeating this advice in our last column as well. Our message is still relevant. Our advice is still the same. Get onboard and get involved!

RAC presents a new opportunity to elevate awareness about our profession, demonstrate our effectiveness and provide exemplary leadership within our organizations. We have the knowledge, skills and holistic understanding of coding and billing to help minimize RAC disruption, protect reimbursement dollars and ensure the process stays on track.

For HIM professionals at all levels, RAC can be the next step in your career ladder and an excellent way to elevate your role within your organization. Thank you for your readership and your comments. We look forward to hearing about your success in 2010!

• For late-breaking news about RAC and timely information throughout 2010, visit HealthPort.

Lori Brocato is currently the revenue cycle management product manager for HealthPort. Nancy Hirschl is president and CEO of Hirschl and Associates, Laguna Niguel, CA.