Eli's Hospice Insider

Target your education efforts by using your self-audit findings.

Don't wait until it's too late to get ready for potential Recovery Audit Contractor reviews of your claims. And the preparation will help you defend against other types of medical review as well.

Now that the Centers for Medicare & Medicaid Services has approved the first home health topic for RAC Performant, a hospice topic may not be far behind (see story, cover page). Heed this advice from the experts to head off potential RAC audits, or at least limit the damage they can inflict:

1. Know what you're up against. CMS has yet to approve any hospice issue for review, but that can change quickly.

"Regularly check the Performant website for updates and disclosures," advises finance expert Tom Boyd with Simione Healthcare Consultants in Rohnert Park, California. The RAC's site, at https://performantrac.com/region-5, also contains links to resources such as ADR submission instructions, Frequently Asked Questions, and outreach materials explaining the RAC audit workflow process.

2. Implement audits.  Before you get hit with a RAC audit, hit yourself with a review. Put in place "random review and claim sampling," Boyd advises. Getting outside eyes to look at them will be the most helpful.

3. Ramp up education. Make sure both staff and referring physicians know what's expected to support a claim. Use mistakes you find in your audits to target education efforts.

4. Prep your finances. Your clinical side isn't the only department that needs to pitch in for RAC audit preparation. Assume claims reviewed by the RAC may not be paid timely and take actions that may be needed to secure your financial viability, Boyd recommends. That may include lining up a loan or credit line and increasing cash reserves, for example.

5. Respond to all ADRs. Additional Development Request nonresponse rate has been named a topic for Targeted Probe & Educate medical review; don't be surprised to see it added as a RAC issue as well. Track your ADR requests and responses to make sure you are hitting the mark.

6. Don't send any old response. When responding to an ADR, agencies must "closely review their medical records before forwarding them to Performant to be sure that all necessary documentation is present to support the medical necessity for the services billed," instructs Judy Adams with Adams Home Care Consulting in Durham, North Carolina.

Tip: Where information is difficult to find in the record, an agency should establish a key for the audit reviewers to identify where specific information is found, Adams suggests.

7. Ask for the RAC's help. Providers that may be overwhelmed by ADR numbers should monitor the volume of claims requested, Boyd recommends. "For example, if 40 records were requested and that would cause financial hardship if denied or delayed payment, then ask Performant to select 10 at a time, resolve the 10, and continue after that," he suggests.

8. Use your industry resources.  "Advise your state and national association if you have been selected, and request assistance," Boyd counsels.