RAC Targets and Triggers
In general, different RAC contractors cover four geographic jurisdictions. Per the regulations, RACs are required to have websites with detailed review information. There is also a three year look back period for claims paid beginning October 2007 and is based on the date of initial payment.
In addition to RACs, other audit contractors and enforcement agencies conduct medical record and billing reviews. These include: Zone Program Integrity Contractors (ZPICs), Medicaid Integrity Contractors (MICs), Medicare Administrative Contractors (MACs), private insurance company auditors, The Office of Inspector General (OIG), and The Department of Justice (DOJ). Unlike RAC contractors, who have specific parameters regarding notice of targeted items, set look back period and civil penalties, the rules governing other entities are often more vague, have unlimited look back periods, and may carry criminal penalties.
Target Areas
- Contractor Targeted Issues (RAC contractor websites)
- DRG Assignment
- Medical Necessity (often CMS standards)
- Non-extensive OR Procedures Unrelated to Primary Diagnosis
Audit Triggers
- Improper or Inaccurate Billing
- Medicare Admission Patterns
- Use of Data Mining
- Higher Utilization than Neighboring Providers
Widespread Impact of CDI
It's now more important than ever before for physicians to ensure that their medical records include documentation that supports medical necessity for both outpatient and inpatient services. The RAC audits are intended to identify overpayments due to incorrect payment amounts, as well as non-covered, medically unnecessary, incorrectly coded and duplicate services. No one can avoid a RAC review, but if all pertinent information is captured on the record, risk is minimized.
Target Areas for RAC Reviews
- Final discharge diagnoses and disposition as well as all appropriate comorbidities and major comorbidities.
- Cases admitted to the hospital but not requiring inpatient status: physicians must assure that patient status is appropriate. ALL hospitals should have a physician admitting order stating “admit status as per case management protocol.” This reduces significant “afterwork” for everyone.
- Three day stays: cases in which patients are admitted to the hospital just to satisfy Medicare's 72 hour window - then sent to skilled nursing facilities.
- One-day stays: clinical documentation should support this short stay.
- Excisional debridement: usually the procedure is not coded correctly, nor is the medical necessity for the procedure established. Physicians should make sure that wound care is documented properly, including whether or not it was a decubitus or diabetic ulcer.
- Services that were ordered as inpatient, but could have safely waited until discharge: inappropriate stays for patient and/or physician convenience. Many services can wait until patients are discharged without jeopardizing quality and safety.
The final RAC determination can be appealed. However, the time involved can be significant for the physician and the hospital. It is vital that documentation support medical necessity for all admissions and procedures.
