Health Care Providers Brace for Medicare Audits

Getting Prepared

While large hospital systems appear ready for the permanent program, smaller physicians’ offices that have more limited resources are less prepared. “Our advice to clients of any size is you have to really pay attention to your compliance efforts. Now is the time to get your house in order,” said Abby Pendleton, also a partner at The Health Law Partners in Southfield, Mich., who co-chairs the firm’s Medicare and RAC Practice Group with Gustafson.

Within a 45-day period, a limit of 10 records can be requested of a solo practitioner, 20 records for a partnership and 30 records for a group practice, said Flora.
Health care providers are preparing for RAC audits by improving record-keeping and documentation and training employees. Based on the demo phase, one area of focus will be in-patient hospital stays. The vast majority of overpayments found by RACs in the demonstration phase – 85 percent – involved in-patient hospital stays, such as short stays or in-patient rehabilitation following surgery, said Gustafson. Given these statistics, providers are reviewing their utilization review processes and whether physicians are admitting patients to the right area of the hospital, Wachler said.

“When providers take a close look at the records, maybe a patient met the criteria for an in-patient stay, but the documentation could be improved so that defending claims is easier,” said Pendleton. In preparation for the RAC program, Andrea Kloubec, senior director of compliance at Park Nicollet in St. Louis, Minn., has established a RAC committee and met with medical practitioners, such as in cardiology. “If you look at one-day stays for congestive heart failure, should this have been in-patient or observation? If we found it should have been out-patient, we set up protocols for [determining] whether it met in-patient or out-patient criteria,” said Kloubec, who said there is software to help with these criteria. Because her organization is a hospital, clinic, hospice, homecare and durable medical equipment provider, she also created five RAC response teams and completed a demonstration of a RAC request. She then tracked how long it took the teams to respond and what the outcomes were. “We’ve timed every person in all stages of doing the RAC response” in order to find which areas could use improvement, said Kloubec.      

Next: More Appeals Expected