Diversified Collection Services (DCS) of Livermore, CA began its affiliation with the Recovery Audit Contractors program when the Centers for Medicare & Medicaid Services awarded it a three-year contract for the Medicare secondary payer (MSP) RAC demonstration contract of California in 2005.
When it came time for the implementation of the permanent program, DCS became the RAC for Region A. Since then —and much like its fellow regional RACs—it has caused providers a plethora of aches and pains since the initial round of record requests were sent.
Despite the setbacks and inconveniences that the RAC process can create, providers can lessen the potential impact and even hope to avoid denials and recoupment by implementing a comprehensive RAC process. Here are a number of tips and concepts to consider when it comes to dealing with DCS:
- Focus on MS-DRGs. The specific list is growing monthly. Keep an eye on your facility's one-day stays vs. observation vs. outpatient in a bed, which may become targets in the near future, according to Stacey Levitt, RN, MSN, CPC, director, patient care management at Lenox Hill Hospital in New York City. "Also focus on short stays of less than 24 hours, but billed as inpatient, specifically for low trim point DRGs," she added.
- Review your charts. Review internal records and charts for lack of coding specificity; sequencing errors (ICD-9); incorrect combinations of codes; failure to assign multiple codes when available; nonspecific signs and symptoms; and use of complication codes, according to Levitt. "Query the physician if documentation is insufficient or nonexistent," she says. "Remember, if it's not documented; it didn't happen!"
- Identify problem areas. Work on any potential weaknesses with your RAC and HIM teams and be proactive, says Levitt. "Review DRG, diagnoses and procedures against DCS targets," she says. "In addition, establish effective communication between the coding staff, CDI program staff, and the medical staff."
- Know your RAC contact information. The DCS project director, Catherine Till, can be reached at (925) 960-4712. The CMS project officers for DCS are Ilene Jacob and Scott Wakefield. They can be reached at (410) 786-7444 and (410) 786-4301, respectively.
- Identify MAC target areas. "Stay ahead of the RACs by understanding the Medicare Administrative Contractors (MACs)," says Michael Taylor, MD, senior medical director, Government Appeals and Regulatory Affairs for Executive Health Resources (EHR) in Newtown Square, PA. By recognizing issues that the MACs are focusing on, it will help to identify potential RAC targets.
- Prepare for the administrative law judge (ALJ) level. All appeals should be detailed and designed to prepare for the ALJ, according to Taylor. "Your argument must address three key components to have a high likelihood of success: clinical, compliance, and regulatory."
- Understand medical necessity. According to Taylor, the decision to admit is a complex medical decision which can only be made after the physician has considered a number of factors, which include: medical history; current medical needs; available facilities; hospital bylaws and policies; severity of signs and symptoms; predictability of adverse happening and findings of diagnostic studies that could assist in decision-making. More information can be found in the.
7 Tips for RAC Region D Providers
18 Medical Necessity Issues OK'd for RAC Review
RAC: The Problem with the Three-day Rule
Stacey Levitt, RN, MSN, CPC and Michael Taylor, MD are speaking in the September 14, 2010 audio conference: RAC Audits in Region A: Strategies for success under DCS.
James Carroll is associate editor for the HCPro Revenue Cycle Institute