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Staffing for Healthcare and Medical Organizations and Government Agencies – PDN in Chicago.

Phone: (708) 747-4361

info@pdnseek.com

The RAC Coordinator

By Joyce McClinton, RHIT

Provena Health System RAC Coordinator

I started this position about eight months ago and have found it to be one of the highlights of my HIM career. As the RAC Coordinator for a large healthcare system, I am responsible for various RAC activities—such as managing work processes, coordinating the appeals process, and sharing RAC findings with key members of the organization. In selecting a RAC coordination team, special consideration is given to HIM professionals because of their knowledge of coding, billing and DRG assignments. This is another great opportunity for HIM professionals; and the number of RAC Coordinators has increase within the last year.

RACs are auditing firms contracted by Centers for Medicare and Medicaid Services (CMS) to evaluate healthcare organizations for the purposes of detecting and correcting improper Medicare payments (overpayments and underpayments). The country is divided into four regions of RAC jurisdiction—Region A: Diversified Collection Services, Inc (DCS); Region B CGI Technologies and Solutions, Inc. (CGI); Region C Connolly Consulting Associates Inc. (Connolly); and Region D HealthDataInsights, Inc. (HDI).

CGI Technologies and Solutions, Inc is the Recovery Audit Contractor for Region B., which includes Illinois, Indiana, Michigan, Minnesota, Kentucky, Ohio and Wisconsin. As of July, 2011, CGI has 176 approved issues from the Centers for Medicare and Medicaid Services (CMS). They are comprised of MS-DRG coding, inappropriate billing errors and medical necessity Issues.

RACTrac, a free web-based survey, was developed by The American Hospital Association (AHA), due to the lack of data and information provided by the Centers for Medicare and Medicaid Services. With over 1,960 hospitals participating, they have provided us with the following results.

It has been reported that CGI Region B has the greatest volume of medical record requests at 62,963 for this quarter with last quarter reporting 49,778. Region B has experienced 43% of all reported automated denials. In Region B, 57% of the denials were MS-DRG related and 36% were medical necessity denials. Region B has the highest overturned rate on appeals at 84% versus the nationwide average of 71%.

RACTrac nationwide survey has reported the following:

· $167 million claims have been reported

· 84% of participating hospitals with complex denials cited medical necessity as the reason for the denial

· Majority of medical necessity denials reported were for 1-day stays

· Syncope & Collapse ranked as the top MS-DRG denied by RACs

· 57 % of hospitals with RAC activity reported receiving at least one underpayment

· 75% reported that RAC affected their organization with 49% reporting increased administrative costs

· 55% indicated they have yet to receive any education

· RAC responsiveness and overall communication was fair or good

· Average wait time for response varied with 18% reporting 14 days or more

Nationwide RACTrac results reveal valuable insights for both participating hospitals and the AHA. RACTrac findings are used to educate the HIM field, reduce RAC vulnerabilities in hospitals and inform CMS and Congress of changes needed to the program.

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