'A Proven Revenue Source for CMS'
"It is frustrating to have significant dollars taken back based on an auditor's retrospective review of the provider's delivery of care based on their professional judgment at the time," she says. "… [T]he auditor has benefit of hindsight and the documentation that becomes available after the intervention and hospitalization has occurred and the outcome at discharge is known… It is particularly frustrating because the dollars have already been expended on taking care of those patients."
Southwest General is tackling the RAC challenge by making efforts to improve clinical documentation, tightening up internal controls, and using an outside service to review its inpatient Medicare cases. But all of that comes at a price.
"We have added charge capture specialist positions that assist with denial prevention. Other than that, the cost to the program is really the opportunity cost of having our director of HIM, case management, revenue cycle, vice president of medical affairs, and others reviewing denials and working with our largely independent medical staff on documentation improvement. Another hard cost is the fees we pay to an outside agency to review nearly all of our Medicare admissions for medical necessity," Freas says.
"We don't expect this process to go away," she adds. "It's a proven revenue source for CMS."