Now as we look forward, the permanent RAC program contractors, in partnership with CMS, are promising significant improvements.

Yet, at a time when the national healthcare agenda has undertaken a massive effort via stimulus dollars to modernize healthcare by making all records electronic, the planned RAC processes for complex record requests remains insistent that  “paper, fax or CD/DVD” are the only acceptable formats.


This is of particular significance when you realize that one out of ten of the 11 percent “other reasons” for inpatient denials in the demonstration project were due to being unable to get the chart sent from the organization to the RAC by the target date.


At a recent provider outreach meeting in Michigan, upon learning that record requests could not be sent electronically in the foreseeable future, an attendee suggested that the RACs consider at least sending an e-mail notification to the provider RAC contact to alert them of the first-class mail request for records. That suggestion was to be taken under consideration. Curious indeed.

Care Management’s Expanding Role

This resource-intense response to RAC audits is prompting acute-care providers to look for rapid process improvement strategies to ensure compliance on the front end. What can be done to minimize the coordination and tracking of the complex record request reviews, avoid denials and limit appeals that we know are coming this summer?


Simply stated: look to your care management service roles and processes.


Care management can provide a dependable resource in ensuring compliance for medical necessity determinations for all payers. This resource also can be invaluable in ensuring that the right thing is done for the patient, linking quality of care with these intense reimbursement issues.


Begin asking some curious questions: how aggressive is your organization in evaluating and improving what could be poor or misunderstood processes for determinations of observation status versus inpatient admission?


What is the care manager’s accountability and authority working with the interdisciplinary team to impact care coordination and eliminate avoidable delays? How well understood and supported is care management’s role in meeting these objectives across your organization?


The shared goal of the internal RAC team and care management is to minimize risk and PREVENT takebacks – thus limiting a lengthy and costly appeal process – with the additional safeguard of doing what is right for the patient.


A key strategy to meet this objective is re-energizing care management’s role in managing how medical necessity determinations are made across all payers, ensuring timely case escalation for physician advisor case review, and raising expectations to facilitate care coordination to the appropriate and safe level.


A PREVENT strategy checklist:


  • Are 100 percent of all new admissions reviewed using hospital-approved criteria for the presenting “severity of illness” and “intensity of services” provided to treat that illness?
  • Have care management/utilization team members received up-to-date education on the hospital-approved screening criteria?
  • Are the admission reviews for Medicare rigidly tracked and completed within 24 hours with the same discipline as the commercial payer reviews?
  • Are medical necessity determinations completed for weekend Medicare admissions with a clear seven-day-per-week definition of who is responsible for the review, versus a  “retrospective review” process?

  • How is care coordination orchestrated, particularly for direct admits and emergency department admissions?
  • Is the documentation of the admission screening review readily accessible?
  • Is there a defined action plan for how to refer any cases not meeting criteria in a qualified physician advisor review? Are they referred for clinical leadership management review?
  • Are Condition Code 44 changes from inpatient to observation status occurring timely prior to the patient’s discharge?
  • Is the additional review by the physician advisor readily accessible and retrievable for internal audit, or for inclusion with a RAC complex chart request?
  • Are the continued stay reviews for Medicare consistently documented at a regular, defined frequency?
  • How aligned is your case management team to communicate effectively with the medical staff who control what happens to the patient?
  • Are the care managers working closely with nursing and medical staff to ask the question, “Can care be safely and effectively provided at a less intense level? “
  • Does the clinical staff team understand the PREVENT strategy and the importance in facilitating care with a correct status determination from the point of entry to your organization?


As the RAC Provider Education sessions continue, keep your sense of curiosity alive and think “PREVENT.”  Be ready to ask questions that can improve your processes, safeguard revenue and utilize care management resources to improve quality of care for patients.


About the Author


Jeanine M. Tome, RNC, MSN, ACM, CPHQ, is Chief Clinical Officer for Allscripts Care Management with a  focus n bringing technology innovation to the care management practices.  Ms. Tome has 33 years experience with inpatient clinical operations leadership in Care Management, Nursing Administration, Quality Improvement and Patient Safety. She is a founding board member and past president of the American Case Management Association.


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