UR or QI nurses with RAC experience? - page 2

by sknelson 4,928 Views | 15 Comments

Are there any UR nurses or QI nurses from CA,FL, or NY that have had experience with Recovery Audit Contractors willing to give advice on how to prepare for the permanent RAC's or share their experiences?... Read More


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    Between you & me, ( and now the world!), Peds cases are hardly ever denied...some unwritten rule that we reviewers and Med Directors honor unless there is absolutely NO medical need found, after many days beyond the recommended length of stays.

    What I do w/my "problem providers" is print out the criteria of the DX's that they are frequently admitting with that should have been OBS status, at max. Especially the "Chest Pain" and "Abd Pain" work ups.

    I am very nice about it, telling them I don't expect them to know, remember all the criteria for every DX, blah blah blah, so here is something to help them when they do their initial H&P. I highlight the definitive criteria that is nec for meeting an IN admit status.

    And I remind them that they can always change the admit status from IN to OBS during the H&P work up if the ER Doc wrote IN.

    AND if they DO find something in their work up the first day, they can change any OBS to IN. Again, if nec.

    When they have been given something concrete in their hands, it also alerts them that they are being watched closely and they take it seriously.

    They take this approach more seriously than any talk of saving tax/insurance dollars; they really don't care about anybody else's money except their own.

    But to imply they do not know the acuity level of patients hits their ego's!

    This has been a very good method to get the drug seekers and frequent flyers out of the hospital in 23 hours.

    By the way, If the patient came to the ER after 3PM, I approve almost all those stays a 48 hour OBS; but that's a personal thing with me.

    Your Case Managers can always point this out to the Reviewers the next morning that are pushing to "Get 'em discharged today" for cases that are late in the day admits.

    Personally, I do not think it is "fair" to penalize the facility by requiring them to do a 23 hour work-up in 13 hours for patients that present to the ER at 11PM; so I just ask my Medical Director to give 48 hour approvals for these cases that are not obviously drug seekers or frequent flyers. He concedes this w/me at least 95% of the time.

    Hopefully, your facility won't suffer too badly w/the RAC Attacks, but if it does, please please please beg your Administrators to deal w/the Docs w/their admits in some type of LOSS-$haring plan, because that's the only way you'll Really get them to pay attention; when THEIR wallets are affected. They can make it part of their terms of admitting priviledges contract, that if their is a pattern of cases that should have been OBS that the hospital is being denied money for now; then the Admitting MD will share a percentage of the losses. The ER Docs should all be admitting (almost) everybody as OBS status except the absolutely worst case "made for ER TV" type of cases; and they can also share in a LO$$ percentage program.
    There is no reason for the facility to have to eat the total loss of Income; they can only bill/submit claims based upon what the Docs ordered.

    We have to keep our hospital's open; and RAC has the potential to close alot of doors; so the best we can do is make a more concerted effort to follow the InterQual &/or Milliman Criteria better NOW; because unfortunately; claims can't be re-submitted/changed after the patient is discharged.

    I don't like that at all; way too harsh as far as I'm concerned. Personally, I think RAC was part of the last ditch efforts of the past administration to make it look like Medicare & Medicaid had alot more money available in the future and not as bankrupt as it is for the incoming regime. And it didn't matter which "party" won/loss this past election, it was simply started to make things appear better than they are; which now, unfortunately, is 100 times worse than we ever imagined.
    Last edit by ImAgypsy on Feb 22, '09 : Reason: To make more readable & add more info.
  2. 0
    Hello Again SK,
    Just came across this site ahima.org w/good info; pages 33 on are informative regarding observation/outpatient services and coding; it's a pdf file you can save

    http://campus.ahima.org/audio/2008/R...8.pdf#page%3D4

    Gypsy, (See what fun I am having on my day off, Sunday Eve!!! The Learning Process is endless in this reviewing business as I imagine it is for you all defending the charges!!! Two sides, same coin!)
  3. 1
    Hi Gypsy! You spend your Sunday evenings like I have spent hundreds of mine!!! Thanks so much for all the info you have given me. Even though I should be in the "defense" mode--the claims the RACs are taking money back on, especially observation and the one day stays are things I have tried to get through to our administration for a long time. Unfortunately they kept their head in the sand and now it's time to pay the piper!! I won't get to see how our RAC adventure turns out. I am retiring the first of next month but the hospital has hired a consulting group to help them with UR and RACs. Now on Sunday evening I'll be setting on my deck deciding what flowers to repot!!!!!
    Sharon
    Rntr likes this.
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    Gypsy--Maybe you can help with this question. Re: obs hours and what is medically necessary. Ex: chest pain r/o mi. Pt placed in obs. Diagnostic tests, such as Echo or Stress Testing, are delayed 24 hrs, but pt is still being monitored on tele. I would track this as an avoidable day for the hospital, but would RAC consider those 24 hours medically unnecessary. Thanks
  5. 0
    Gypsy, can you tell me what start times and end times my hospital needs to be using to caluculate hourly observation charges? on your ahima document above states that it's when the patient 's medical intervention would end, I take that for an IV being discontinued and d/c instructions being given. Is that right?
  6. 0
    ImAgypsy,
    I agree with everything you said and would love to do RAC reviews myself. Were you paid per chart / hourly or salary? Did you go onsite / office or work from home?


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