Yes, I am a former CMS RAC Reviewer who reviewed charts from 2003-2007
in the states of Florida and South Carolina during the CMS Pilot Project last year.
And, I actually enjoyed doing these reviews and feel very strongly that the RAC
is necessary to break the cycle of inappropriate billing by facilities. (Reason why at end of this epistle!!!)
As far as any facilities being able to "prepare for a RAC review"; the nature of
the review being Retrospective; After it has been submitted to CMS for payment;
really puts facilities in bind; so I would recommend that ALL Summaries be in
the chart, and especially focus on measurable documentation that led the provider to decide whether or not the patient should have been admitted as Inpatient vs. Observation (also called Outpatient) status.
The big lack of knowledge by Providers is that they do not understand or accept that
Inpatient Status, which is paid by Medicare Part A funds, Must Be Supported by definitive findings.
Such findings, ie. Pt. comes to ER, c/o Chest Pain, second Troponin elevated, some S-T wave changes on EKG; Justifies the Admission Status and Subsequent Care/Work-Up as InPatient.
An Inpatient Stay will pay the facility More money, based upon the DRG/ICD-9 Coding for MI, Acute. The facility gets more money because much more care is involved with a patient who has truly had a MI vs. a "Generic Chest Pain" admission.
This vs. Your "Generic Chest Pain" admissions, present to the ER, may be c/o all the classic symptoms; but no definitive findings are found. ie, 1st and 2nd Troponin WNL, Non- ST wave EKG aberrations, etc.
These folks get to be admitted under the "Observation Status" which is paid for by Medicare Part B funds. Yes, they get a room, a bed, tele, tests, everything; Nobody has to worry "They'll SUE me if I don't admit them".... The work up and stay are simply paid from separate federal funds.
If, within the first 24-48 hours of an Observation stay, definitive findings ARE proven, then, the claim/admit status order, Before the Patient has been Discharged; can be ordered & changed to InPatient Status, providing evidence of Intensity of Services was provided to the patient who has now been found to meet the Severity of Illness criteria.
These are the types of scenarios that RAC is looking for. There is actually very little that a facility can do months after a patient stay to change the outcome of the review; despite all the appealing done. Either the patient met Severity of Illness and Intensity of Services were delivered, or they did not.
Peers, for too many years, Providers have been admitting patients under the wrong status and Case Managers/Administration have not been "aggressive enough" in letting the Provider know that the admission is not meeting both SI (Severity of Illness) AND IS (Intensity of Services) by InterQual Criteria; and this is part of the big problem that has helped to bankrupt the Medicare coffers.
Look at it this way; I have two bank accounts. One is for all the "Must Haves" in life;
Rent, Utilities, Insurances, Car Payments, Food, Gas.
The other is for "Want to Haves"; New Clothing, Entertainment, Trips, Gifts.
If I keep taking from Account Number One (Medicare Part A- Inpatient, Truly Sick, Hospital Admissions/Stays) to pay for things I want that I could have most likely done at another time (Medicare Part B- Observation, OutPatient, Ancillary, Procedures, services);
Soon I shall have no money in Account One to pay for the "Must Haves".
I feel that as nurses, we all need to have the courage to keep educating the admitting providers over and over and over again until they realize the difference in the 2 admitting statuses, and that YES, Their Patient Does Get a BED, They Can Work Them Up, at an Observation/Outpatient admitting Status. If they do not find something within 24-48 hours; then discharge the patient and complete the work-up at outpatient facilities; and have Medicare Part B funds pay for it.
The Hospital will get MORE money from Medicare Part A if the work-up actually proves something is wrong with the patient. But not a moment before!
Remember, These are all of our Tax Dollars that have been depleted. And I, being one of those "Boomer Year Nurses" am looking forward to some of the dollars I paid into the system being there for me; and not having been wasted on every drug-seeker presenting to the ER c/o "chest pain" who had absolutely NO evidence of having an MI, or other major chest related illness; within their first 24 hours of hospitalization.
Of Course there is much more involved than the simple examples I have given.
But I do feel that RAC will eventually be seen as corrective, not punitive actions.
And, if anyone needs a former RAC reviewer to do it again, please PM me! I like it!