by AJ Riviezzo
Apparently, Medicare had decided to balance their budget on your labor. With the proposed cuts to reimbursement and the dramatic increase in Recovery Audit Contractor program (RAC), there seems to be a big push currently to retain and recoup as much money as possible.
Over the past six months, the number of calls I have received regarding RAC audits had quadrupled. If you have not been involved in a RAC audit recently do consider yourself fortunate for now. I do believe this pace will continue as we have seen no ebbing of this tide.
The RAC organizations are contingency based. The contingency fees vary, but they have a very strong financial incentive to find errors and omissions. In the vein world, they seem to be focusing on two elements. These are:
Conservative Therapy – If conservative therapy was not performed by the treating physician and documented in the chart you will not pass the first round of the RAC audit. Taking the patient’s word that they have self-completed conservative therapy is NOT being accepted. One physician who primarily treats patients who have been treated by a wound care entity is facing denials because the documentation in the wound care charts regarding conservative therapy measures is inadequate.
Vein Size – This has been primarily a Novitas issue due to their very oddly written policy which has since been replaced, but it has been an issue in some other administrative areas as well.
What to Do if You Receive an Audit Request:
First, be sure to reply in the timeframes specified. Lack of response is an automatic fail.
Second, send everything pertinent. My regular list included the History and Physical, Diagnostic Ultrasound, progress notes (if any) regarding conservative therapy or completion of same, and the ablation report. If two different dates of service are being requested, I would send the complete packet for each date of service. It is better to assume they are not ‘sharing’ data from one request to another even on the same patient.
Third, you cannot amend the chart at this late date. If something is missing or the chart is not as robust as you would like it is, unfortunately, what it is. Sometimes there is other data in the patient’s documents or an MA’s notes that can help further justify the treatment process.
Finally, if you fail on the first round, there are appeal processes. We have seen a good percentage of these denied claims overturned on appeal. Of course, the better the documentation the better chance of overturning the denial. It is your money they are trying to take. Fight this until there is no fight left. It seems that once the auditors find an easy way to obtain their ten to twelve percent of your money, they will continue to send more and more audit requests.
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