Recovery Audit Contractor (RAC) Denials. 2010 Lean Symposium 4/20/2010 Presented by: Dennis McInerney representing The RAC Team. $. The RAC. $. 2008-Present IHDM RAC Team Charter. The RAC. Team Senior Leader: Mark Purtle, CMO Team Leader: Patty Armstrong
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2010 Lean Symposium
Presented by: Dennis McInerney representing The RAC Team
Senior Leader: Mark Purtle, CMO
Team Leader: Patty Armstrong
Team Members: David Stubbs; Kara Dunham, Crystal Estabrook, Kim Hill, Nici Johnston, LeAnn Kai, Brenda Long, Barbara McLeod, Theresa Miller, George Morgan, Debra Myers, Susan Searcy, Glenda Seemiller, Janet Stipe, Joy Trude
Dennis McInerney and Ray Seidelman
Aim: To produce a complete and accurate medical record for each patient encounter that reflects the quality and value of healthcare delivered. By August 31, 2009 the team will have implemented new processes which will achieve these goals.
Current State: CMS has hired the RAC (Recovery Audit Contractors) who are scheduled to identify and recoup improper Medicare payments. RAC implementation for Iowa is tentatively scheduled for Aug 1, 2009. On this date they will start to audit retrospectively back to Oct 1, 2007. It is estimated based on RAC take-back history that IHS-DM is vulnerable to an average annual $2.8MM loss (200 records every 45 days, take back rate of 35%, and average $5k per claim).Currently the processes and documentation that produce our medical record are prone to errors and rework. We want to review , standardize and improve these processes. We also do not have a process in place to address response to RAC letters.
FOCUS: To develop a process for responding to RAC's by Aug 31,2009. This will consist of a baseline assessment of risks and development of processes: 1) to track and respond to RAC's denials and medical records requests, 2) to continuously improve documentation in the medical record in support of the RAC team aim and 3) to successfully implement these processes.
Average 72% Improvement!
Oct09 – Mar10 Positive Improvement from baseline
Reduction in total LOC changes this March and a low of 6% Error Rate
Process Simulations & Overpayment Identification & Disclosure
Design New and Improve Existing
“Design in” RAC record submittal, appeal, and CBO/HIM/CM processes.
Improve the accuracy and completeness of current and future medical records
Identify and fix any RAC impactful errors in past medical records and minimize financial loss
Automated Denial (“N432” posted”)
46 mins / record
Assuming 20 day
Complex Denial (“Requires Medical Record Review”)
2Error ReductionFacts about Current Medical Record
From the floor …
In general current medical record contains:
Note: No Care Cast info added
YIKES, Where do we start?
Based on the prioritized documents, sub teams were formed to verify potential risk, provide root cause analysis if needed, implement solutions, and ultimately improve accuracy and completeness.
Please bring on the EMR…
Reduce potential denial pipeline by self disclosing known, unrecoverable, overpayments