Highlands RAC team is composed of the Controller (Ted), Compliance Officer, Chief Nursing Officer and representatives of Health Information Management, Utilization Review, Clinical Documentation Improvement, Billing, Patient Registration, and the Physician Liaison.


This multi-disciplinary group meets weekly to review the status of their action plan roadmap and to examine any news related to the RAC.


The Assessment


Ted began the Highlands RAC program in June 2009 by conducting an assessment of the operational, coding, and documentation areas key to RAC survival.  The assessment results provided the roadmap for the RAC team to spring into action.


The first action the group took was to address the issues from the assessment.  Policies and procedures were written or revised to detail the processes that would be in place to meet the requirements of responding to RAC requests and reviews. New protocols and forms were developed.  Members scour the Web (especially RACMonitor) and journals for information about the RAC program and the approved targets.  Team members have reviewed the billing edits for single unit billing codes and claims for inpatient discharges posting outpatient only procedure codes.




To determine if there is any risk in the targeted DRGs, hospital staff are auditing records for the previous 13 months.  They are reviewing records assigned to Medicare’s top 20 discharges, looking at all 1-day length of stays (excluding transfers, deaths, and AMA discharges).  Medical necessity documentation is compared to the InterQual guidelines.  PEPPER reports also provide good information about possible areas for review.  If any payment errors are found, the hospital immediately rebills and, if necessary, refunds payment.


Although Highlands has not had any RAC request letters to date, the hospital is ready to respond. Highlands RMC is currently using the AHA RACTrac program to track the dates and times and actions for all RAC activity.  Ted has modified the program slightly to be able to track queries and denials from all sources.  When the RAC does request records, the documents will be scanned into a database so the hospital will know exactly what information was sent to the RAC.  The documents will be mailed to the RAC certified mail, return receipt.


Helpful Advice


When asked what advice he had for hospitals, Ted exclaimed, “Don’t Wait!! Get Started!!”  Get an assessment to use as a starting point.  Then form a multi-disciplinary committee based on the scope of areas within your facility.  For example, if a facility has an Internal Audit Department, a representative from that group would be important to have on the RAC committee.


Establish protocols so that all the key personnel will know how to respond to requests for information, demand letters, appeals, etc. In the RAC pilot program, a number of denials were due to facilities not providing the requested information.  Failure to provide requested information is an operational issue that should never happen.  A communication program is essential for all levels to understand the RAC processes.  Ted emphasized that being ready for RAC reviews takes a lot of time.  If hospitals do not have that bandwidth with existing staff, they should work with outside firms to do assessments and/or audits of records.


About the Author


Cheryl E. Servais, MPH, RHIA, has more than 25 years of experience in health information management. In her position at Precyse Solutions, Ms. Servais’ responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the executive and board levels and takes an active role in professional organizations.


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