Is Your Practice Ready For the RACS?

J. Claypool & Associates | Spicewood, Texas
800-227-4594 (in Texas) or 512-264-3323 (Austin)

by Jamie Claypool

The CMS, after a pilot study over the last 3 years involving 3 states, will now contract permanently with Recovery Audit Contractors, better know as the “RACS”. The program will be expanded to all 50 states. Physician Part B claims will be included in the reviews conducted by these companies. Texas will be included in Region C, and the RAC contractor for our state will be Connolly Consulting Associates, Inc. of Wilton, Connecticut. Get ready for some intense times beginning March of 2009, when this RAC company begins in Texas to review utilization patterns and claims for Part B physician claims/payments. The purpose for using Recovery Audit Contractors, according to the CMS, is to continue to reduce waste and over-spending, and to decrease and/or to eliminate fraudulent claims. The companies will focus on providers and suppliers whose billings for Medicare services appear higher than the majority of providers and suppliers in the community, or appear higher for the specialty group.

If you have the dubious honor of being called upon by one of these companies, you will most likely be asked to submit documentation to substantiate your claims. It is difficult to anticipate what happens after that, as the process has not been made very clear. Some physicians who, in the past, have had reviews by the CMS or Medicaid companies have complained that they were asked to submit documents, but never knew the outcome of these submissions. Many have gone with the “no news is good news” attitude. For some, that may be fine, but the old adage “if you fail to prepare you prepare to fail” comes to light. Being prepared is the first step in dealing with these audit contractors.

How can you prepare for the RAC companies? Below are some things you can do right now to make sure your coding/billing/documentation is in order:

1. Take a sampling of your claims and look at the backup documentation, then ask the following questions:

a. Is the documentation where it should be in the paper or electronic chart?

b. Can you read it?

c. Does the documentation support the services you billed? This element can be tricky if you do not have a good grasp of coding –especially the E&M codes.

d. Is medical necessity documented, or inferred, in the record?

e. Is your rationale for ordering services clear from the record?

f. Are the results of the services you ordered in the record, and have you signed off on them?

2. Bring your coding knowledge up to date by attending a coding seminar or “webinar”. The Trailblazer Health web site has coding exercises for E&M services for physicians and office staff- www.trailblazerhealth.com (then go to “Med Learn”). You may also want to bring in an expert(s) for an educational review or training; or self-audit your own claims routinely if you have the expertise in house.

3. Make sure that you have not ordered tests because of patient demand. Some physicians allow patients to “run the show”, so to speak, and overly assertive or concerned patients demand tests and other services that may not be appropriate. Although the majority of physicians do what is right for the patient, some succumb to patient demands and might have some exposure in this area. If it’s not medically necessary, or there is some doubt of the necessity and you still provide the service, be able to substantiate the reason why in your medical record. Ask your billing staff or service to explain the use of the Medicare ABN ( Advanced Beneficiary Notice) to you and to the patient. An ABN is a waiver which allows you to bill Medicare for the patient, but at the same time you are acknowledging that the service may not meet medical necessity requirements, and the patient agrees to pay for the service if it does not meet medical necessity requirements. The claims that are submitted with ABN waivers take the modifier “GA”, to denote that an ABN was signed. Appropriate use of ABNs can help physicians with patient demand for services which may not be deemed medically necessary. An ABN must be signed for each service rendered.

4. Do not make the mistake of thinking you are exempt from reviews because you have an electronic medical record that does the coding for you. Reviewers are looking at these electronic records, or “templates”, that simply repeat from one patient to the next the same HPI, ROS and Exam. Some systems rely on the counting of elements and force you to document a complete review of systems when it may not be at all necessary. Additionally, read the electronic record after documenting, and make sure that what you say in the HPI is not “denied” in the ROS - auditors are particularly attuned to this problem.

5. If records are requested, respond timely to the request. If your billing staff or service receives the request, make certain they know to respond in a timely manner. No response, or a late response, may cast suspicion when there is no real fault. You must be compliant, and you must send the record requested in a timely manner; it is the law.

Finally, if you have made errors (especially with inadvertent over-coding) simply accept the fact, refund any amounts, and move on. Too many times, physicians become overly worried over a situation that can be rectified in a simple and accurate manner. If your documentation is clean and it substantiates your claims, you have nothing to worry about. Being prepared ahead of time for what is coming soon is the best possible course of action.

Jamie Claypool CMPE is a physician practice management consultant who specializes in billing and coding. www.jcassociates.org. 800-227-4594

 

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