Mount Sinai VP talks cost, burden of RAC audit uptick

Mount Sinai Health System in New York City spends more than $1 million annually to manage and defend itself against third party recovery audit contractors.

James Jones, MD, Mount Sinai vice president of administration and senior medical director of clinical documentation quality and improvement, told RACmonitor the demand to keep up with audits is near impossible.

Dr. Jones said Mount Sinai receives between 200 and 250 audits from payers each month. Considering the full length of the audit life cycle, employees handle about 2,000 audits at any given time, Dr. Jones told RACmonitor.

Hospital systems across the country have faced similar problems. Medicare audits have ticked up 936 percent in the last five years as RACs deploy big data analytics tools to trawl through claims and target providers' vulnerabilities.

Managing the deluge is costly. Mount Sinai created a finance department specifically devoted to addressing and appealing third-party audits. Because many payers do not have secured electronic correspondence, the hospital must print, scan and mail each audited medical record to the payer.

"As you can imagine, a medical chart can be up to 300 pages," Dr. Jones told RACmonitor. "This comes as a significant cost to hospitals."

In the end, Mount Sinai's success rate for overturning audits is only about 20 percent, Dr. Jones said.

Dr. Jones is one of many hospital and healthcare advocates that have argued auditors' use of statistical analysis to downgrade medical claims does not account for the reality of the patient's condition or medical treatment. This can harm hospitals' bottom lines and the integrity of their clinical documentation.

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