The CMS National Recovery Audit Contractor (‘RAC’) program implementation is creating a national healthcare vortex!

By Patricia Dear, President of eduTrax®

'Vortex' as defined by Webster's is, "fluid flow involving rotation...whirlpool; a situation regarded as drawing into its center all that surrounds it". Since the RAC demonstration (2005-08) proved wildly successful in identifying and recovering Medicare dollars, and the Centers for Medicare Medicaid Services ('CMS') announced the national programs implementation, a virtual Vortex has enveloped the healthcare industry.

Some hospital providers, physicians and other provider types are more than 'sick' of hearing about the RAC program, some are well on the 'take action'  and 'get on with it' platform, while others still have no plan or have no idea what the program means to them, nor likely the impact they will experience. How is that possible, to have such a difference in knowledge and state of readiness for such a significant event in the 'revenue life' of Medicare fee for service providers?

I recently spoke to a group of very talented and bright physicians, all committed to their community, hospital and the survival of their own practices. More than ¾ of the audience of greater than 100 had NEVER heard of the RAC, did not know what a MAC (Medicare Administrative Contractor) was, and in fact were not sure of why the hospital CEO insisted they attend the evening meeting featuring the topic.

When I asked the group how many (if any) thought they were adequately reimbursed by Medicare, not one indicated that sentiment. Rather ALL felt they were not reimbursed sufficiently, it was 'too difficult and time consuming' to get paid, and if an alternative to Medicare reimbursement could be found they would (gladly) seek it! Another interesting sentiment expressed by the same group surrounded the question of "Who is your best payer?" The immediate and unanimous answer was "Medicare, hands down, they pay best." Perhaps this is more of an indictment of other payers, however given the disparity between the perceptions by the same group of the country's single largest payer it presents quite a conundrum. Why the disconnect?

I have never experienced a tornado (thank Heavens!), I imagine however the terror of a huge wind vortex with an apparent 'mind of its own'; swooping down where it happens to land, hopping over some homes and destroying other completely, debris of all kind thrown about. Some homes survive, some don't; and then it moves on and then is completely gone. This is just the kind of over whelming chaos I imagine when I travel to facilities and physician practices, look at the faces of the staff, and listen to the concerns of many in healthcare today.

I hear a lot of the same questions from providers. "When do we start getting demand letters? What impact will RACs really have? How long will the RACs be around? They're going to hit the "big guys" first, right? The focus will only be on Hospitals and surely, they won't come after little ol' me, right?"

Since the advent of the permanent RAC program, quite a 'cottage industry' of professionals, consultants, and IT companies have arisen, each with their own spin on how to help the provider. The din of information has caused some providers to become selectively deaf or blind (perhaps they view this as just a repeat of the Y2K scare), others to become ambivalent (hey, it won't be that bad), others to over-spend trying to 'buy the answer,' and still others to get downright livid!

Let's get serious, since this IS serious. Is this rocket science or not? Why does this seem so complicated? What is the root of the problem? Actually, you probably know the answers:

• No, it's not rocket science, but it is medicine, which does seem to involve more than just science;
• It seems complicated because it IS, since it involves individuals, who are not machines, and are actually quite complex;
• And the root of the problem is... wait for it... you guessed it... DOCUMENTATION.

Why documentation? Because payment contracts with specific (?!) language is involved. You, the provider, have a contract with a (so-called) payer, to provide very specific services in very specific circumstances. Ever notice that RAC denials (and others) have little to nothing to do with actual care provided? Remember a statistic I have often quoted, which is taken from the report on the pilot program that launched the RACs:

"About 83% of RAC Denials were for preventable coding or documentation errors."

Electronic Medical Record companies are attempting to provide solutions and filling your mail box with offers. Documentation Specialists (with a new certification as of May 2009) are trying to provide solutions inside facilities. Many providers are adopting new Case Management Protocols, or enhanced Utilization Review to provide better support for documentation. Just recently I heard of a national company started by Physicians who are utilizing 'evidenced based' Physician 'speak' to allay fears and defend language is contained in the patient record. A dizzying array of potential solutions - there's the vortex I started this article with. Which solution from the vortex will work for you?

Like Dennis Hopper says in those TV ads, "My friend, you need a PLAN."

In a June 2009 webinar on the RAC Appeals process, attendees (almost 100 facilities) were asked if they were ready for the RACs. One third said they at least had a plan in place. Another third said they were talking about a plan. The final third said they had not done anything yet. Which third might you fall into? Are you still caught up in this vortex?

Can we agree that perhaps, the answer to escaping the vortex (like the tornado) is best managed in this manner:

1. Assess the risk (where is it);
2. Make preparations in advance (yes, maybe us at RAC University);
3. Locate a basement (a base of operations, actually... how about medical records? I'm not joking!); and
4. Develop a survival plan (appeals, internal audits, appeals, external audits, process to assist MDs in documentation, did I mention appeals?)

Here's an example of one tool eduTrax® created to help facilities improve their documentation. Essentially, it often replaces the need for a query to be sent to a physician. As most of us know, coders and case managers are continually asking physicians to be more specific, and physicians often come back with a common refrain, "Tell me what to say then!". Support tools and personnel can help with what to cover in the documentation focused on diagnosis specificity, which accurately describes the patient, situation, findings AND improve reimbursement and future revenue defense from entities like the RAC.

The eduTrax® tool below is designed to do exactly that. The screenshot below is what is provided when an eduTrax® user seeks documentation support for a common diagnosis, such as Congestive Heart Failure or CHF.

As you can see, the tool provides a list of topics the MD needs to cover in their documentation which will optimize the coding and therefore the probable reimbursement, which is no more and no less than what the facility is entitled to receive. Use of a tool like this has improved physician documentation and reduced coding error rates from a high of greater than 50%, to almost zero errors, within a month or two of use.

The above represents one straightforward and simple approach to improving Physician documentation. Whatever resources are chosen, avoiding the Vortex of the RAC's is not likely; SURVIVING the Vortex is the only option and to do that you must have a plan, and a safe route!