Nancy Hirschl, CCS	Lori Brocato

Knock, Knock. Who's There? RAC
As mentioned in earlier columns, your RAC team should have already identified who will receive RAC record request letters and serve as the primary point of contact for correspondence with the RAC. Ideally this will be a designated, full-time RAC Coordinator or Chief RAC Officer. In smaller organizations the burden often lies in HIM. This person or team of people serves as the "front door" to your hospital where the RAC is concerned. Responsibilities include:

• Serve as official recipient for record request letters and RAC correspondence.
• Enter information and initiate tracking process for each request received.
• Monitor deadlines, track appeals and ensure compliance with RAC requests.

First and foremost, do you have enough ROI staff to handle an increased volume of requests? If ROI is outsourced, meet with your vendor to make this determination. Secondly, the request letter should be logged into your RAC tracking system, including specific case information, date of letter, date of receipt and the issues in question.

Step One: Request letter is received and logged. Records are reproduced and sent to RAC within 45 days.

Your Task: Identify key point of contact for RAC. Analyze workflow, staffing and technology for ROI.

Depending on your record format, your outsourced ROI vendor or internal staff will gather the records requested, reproduce the documents and send them along to the RAC. During the demonstration project only one RAC was able to receive documents electronically, but it is anticipated that all RACs will have this capability as part of the permanent program. Organizations should keep a copy of all documents sent to the RAC either in hard copy or electronic version.

RAC Who? RAC Determination
In the second step of RAC workflow, your organization will review cases requested by the RAC. This can be done for all cases requested by the RAC or retrospectively following the receipt of a negative RAC determination (described in more detail below). At this point in your RAC workflow, retrospective chart review for only the denied or questionable cases is your best choice. In other words, wait to conduct chart reviews until a negative RAC determination letter is received.

If you have performed proactive review of expected RAC targeted cases your organization will have either:

• Reduced RAC demand letters;
• Identified and corrected potential RAC targets;
• Mitigated RAC risk

Be sure to document the dollars-at-risk for each determination letter within your RAC tracking tool.

Step Two: RAC determination letter is received within 60 days. If a negative determination is made, the case should be reviewed.

Your Task: Determine which type of case review you'll conduct - proactive or retrospective. For each type of issue or denial, identify the appropriate person to review the case.

The Appeal Process Begins
The last key step in RAC workflow is the appeals process. For each case reviewed in step two, your organization must decide whether or not to pursue an appeal. We'll provide more detail on making this decision in a future column. The bottom line is that not all cases will be appealed-nor should they be.

The appeal process involves multiple steps, a lot of coordination and a plethora of internal and external resources. Recent changes to the RAC appeals process provide more steps and choices for hospitals in dealing with financial recoupment.

Your first (Level 1) appeal letter must be received by the RAC within 30 days (rather than the originally designated 120 days). The American Hospital Association's Regulatory Advisory published on March 27, 2009 states, "To qualify for a stay on recoupment, the redetermination request must be received and date stamped in the Medicare contractor's mailroom within 30 calendar days of the date of the demand letter." Your RAC tracking system should help keep you apprised of deadlines and assist you with each level of review and appeal.

Be sure to include your Patient Financial Services (Business Office) in the RAC process as they will deal with actual RAC financial actions. Of note, hospitals will be notified of pending RAC recoupments with the use of a new Remittance Advice (RA) code "N432." An RA with "N432" will report the recoupment amount designated in corresponding demand (denial) letters received by the hospital.

In the demonstration project there were three levels of appeal and a notable percentage of cases were overturned at the final, third level. The permanent program allows for up to five official levels of appeal. In evaluating RAC workflow, it is important to understand each step in the appeals process:

1. Record review (internal or external consultants)
2. Review case and decide if it warrants an appeal. If so, write appeal letter.
3. Send appeal letter and accompanying documentation to RAC.
4. Receive next RAC response, determination letter, within the next 60 days.
5. Repeat the process up to fifth level of appeal.In evaluating RAC workflow, it is important to understand each step in the appeals process:

Step Three: Decide which cases to appeal and work through the appeals process (submit letters, receive response, determine next step).
Your Task: Identify a core team of professionals to serve as your appeals team. Track all letters, deadlines and additional documentation submitted through each level of appeal.

These three key steps: receiving request letters, reviewing RAC determination letters and processing appeals are the foundational pillars of RAC workflow. Once you understand the basic process, you'll be better able to evaluate your current resources, identify gaps and make a more informed decision to fill the void: hire additional resources, outsource specific tasks or outsource the entire process.

Stay tuned next month when we delve into the specific technology requirements for RAC tracking.