UR or QI nurses with RAC experience?

  1. 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?
  2. Visit sknelson profile page

    About sknelson

    Joined: Dec '08; Posts: 6; Likes: 1


  3. by   Ginger's Mom
    RAC is an intense audit. When they came to my hospital there were several nurses with laptops. I don' t think there is anyway to prepare since each hospital's medical records are different.
  4. by   OC_An Khe
    The only way to prepare for a RAC is to always be ready. Your coding and documentation needs to be excellent otherwise your facility will lose $$$$.
  5. by   Triage24
    I am a former UR nurse in S. Carolina. RAC will provide a list of who, what, why they are recouping any money. Appeal everything possible. You must have people looking at these charts who live and breath Interqual. People who can quote Interqual to you. Go into it with a clear understanding that you will not win all appeals. Your goal is to win as many as possible. Appeal has to be based on Interqual criteria. The record must show Severity of Illness and Intensity of Service. They are not intrested in anything else except that. Remember they are contracted to recoup money they get a peecentage of how much they recoup. The less you appeal the more they get. Iin summary appeal, appeal, appeal
  6. by   sknelson
    Thank you for the information. How did you track the RAC activity; excel spreadsheet, other software,etc? I am at a hospital in Kansas and we are scheduled to start with RACs in August.
  7. by   Ginger's Mom
    I am sorry I misread your initial post.

    First of all, our hospital did not get much lead time was charts to pull, I believe it was less then a week for hundreds of charts.

    Second, know your Medicare regulations! Review them as painful as it maybe.
    Make sure proper documentation is done in a timely fashion.
  8. by   ImAgypsy
    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!
  9. by   sknelson
    Thanks Imagypsy!!!! I really appreciated your reply and insight!
  10. by   ImAgypsy
    You're very welcome SKNelson; please just encourage the nurses, case managers, social workers, whoever is doing the initial review to see if the patient meets observation vs. inpatient status to "be brave" and let the admitting provider know. It's better to get some of the observation Medicare Part B dollars than to be totally denied every dollar if it was an inappropriate billing to Medicare Part A. Right? We aren't denying anybody initial services/work ups; just managing the few dollars left for future payments. I am reviewing Medicare & Medicaid cases again, what a nightmare with the latter. No Co-Pays for the Medicaids means alot of abuse of using the ER for visits that they were too impatient to wait for an appt w/their PCP. I wish the Medicaids had to pay something, anything, $5-10/per ER visit. That might cut down on the abuse. Uh,Oh, I better get off my platform! Gypsy
  11. by   sknelson
    Gypsy--I really appreciate you sharing your information!! We have a problem with the Medicaid too. We have only two physicians (pediatricians) in our town that will see Medicaid patients, therefore we have a problem in the ER. And of course we have a problem with observation and a really weak UR process. RAC's will not be fun for us!
  12. by   ImAgypsy
    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.
  13. by   ImAgypsy
    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


    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!)
  14. by   sknelson
    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!!!!!