Hospital need to restructure themselves to reduce claims denials by recovery audit contractors, says Elizabeth Lamkin, CEO of Pace Healthcare Consulting in Hilton Head, S.C. Here she offers nine ways to add or change committees, enhance reporting and create new positions to improve RAC compliance.
1. Put committees in charge. Some hospitals put a RAC coordinator in charge of all RAC duties. However, "this work is too much for one person," Ms. Lamkin says. One person won't be able to bring together all the separate silos in the hospital that do not talk to each other. And one person may lack the authority to carry out basic changes in the hospital culture to improve compliance. "You need a more comprehensive approach," she says.
2. Create a RAC committee. If the hospital doesn't have one yet, create a RAC committee bringing together case management, physicians, nurses and other hospital silos, such as a compliance and utilization management. This panel reviews denials, pinpoints the causes and implements changes to avoid them. It should include someone from the C-suite to enhance its authority. "The RAC committee is the warehouse for RAC work where, for instance, the revenue cycle team reports on denials and the cause for denials," Ms. Lamkin says.
3. Add CFO to performance improvement committee. With the CFO on the performance improvement committee, financial and clinical staff can closely collaborate to resolve claims issues. For example, both groups need to collaborate on updating information required by the chargemaster, which is filled out by clinical staff as the basis for billing the claim.
4. Revenue cycle committee should report to RAC panel. Since the revenue cycle committee oversees claims processing problems, it should be closely linked to the RAC committee. To improve effectiveness, the committee should also report directly to the CFO.
5. Create a chart audit committee. If you don't have one already, create a chart audit committee that examines a sample of charts covering current and former patients. It should include the physician advisor, nurses, case manager, medical records person and someone from the revenue cycle committee.
6. Send reports to the C-suite. The C-suite should get monthly reports on three metrics that best describe the hospital's RAC readiness. The first metric is the number of "bill holds," claims that had to be held back due to lack of information. The second is the number of denials and chief reasons for them. And the third is on the number of queries coders send to physicians to clear up questions about the chart. These metrics can be broken down by physician, diagnosis, payor or other categories.
7. Report to the board. Since billing compliance could turn into a fraud issue, the board should be in the loop. This can be limited to high-level reports encompassing just a few slides of information.
8. Hire a physician advisor. This is a relatively new type of position, held by a physician, to help ensure care is delivered according to CMS rules. The physician advisor makes daily rounds and monitors ongoing documentation, comparing it with CMS criteria. This person also oversees quality and utilization review and works closely with the medical records department.
9. Use admissions case managers. The admissions case manager examines charts and works with physicians and the physician advisor. "He [or she] keeps his [or her] eyes on the admitting physicians and bed placement," Ms. Lamkin says. "You have to have a gatekeeper for this in order to act quickly." The hospital has only 24 hours after admission to change a patient's billing status.
Learn more about Pace Healthcare Consulting.
1. Put committees in charge. Some hospitals put a RAC coordinator in charge of all RAC duties. However, "this work is too much for one person," Ms. Lamkin says. One person won't be able to bring together all the separate silos in the hospital that do not talk to each other. And one person may lack the authority to carry out basic changes in the hospital culture to improve compliance. "You need a more comprehensive approach," she says.
2. Create a RAC committee. If the hospital doesn't have one yet, create a RAC committee bringing together case management, physicians, nurses and other hospital silos, such as a compliance and utilization management. This panel reviews denials, pinpoints the causes and implements changes to avoid them. It should include someone from the C-suite to enhance its authority. "The RAC committee is the warehouse for RAC work where, for instance, the revenue cycle team reports on denials and the cause for denials," Ms. Lamkin says.
3. Add CFO to performance improvement committee. With the CFO on the performance improvement committee, financial and clinical staff can closely collaborate to resolve claims issues. For example, both groups need to collaborate on updating information required by the chargemaster, which is filled out by clinical staff as the basis for billing the claim.
4. Revenue cycle committee should report to RAC panel. Since the revenue cycle committee oversees claims processing problems, it should be closely linked to the RAC committee. To improve effectiveness, the committee should also report directly to the CFO.
5. Create a chart audit committee. If you don't have one already, create a chart audit committee that examines a sample of charts covering current and former patients. It should include the physician advisor, nurses, case manager, medical records person and someone from the revenue cycle committee.
6. Send reports to the C-suite. The C-suite should get monthly reports on three metrics that best describe the hospital's RAC readiness. The first metric is the number of "bill holds," claims that had to be held back due to lack of information. The second is the number of denials and chief reasons for them. And the third is on the number of queries coders send to physicians to clear up questions about the chart. These metrics can be broken down by physician, diagnosis, payor or other categories.
7. Report to the board. Since billing compliance could turn into a fraud issue, the board should be in the loop. This can be limited to high-level reports encompassing just a few slides of information.
8. Hire a physician advisor. This is a relatively new type of position, held by a physician, to help ensure care is delivered according to CMS rules. The physician advisor makes daily rounds and monitors ongoing documentation, comparing it with CMS criteria. This person also oversees quality and utilization review and works closely with the medical records department.
9. Use admissions case managers. The admissions case manager examines charts and works with physicians and the physician advisor. "He [or she] keeps his [or her] eyes on the admitting physicians and bed placement," Ms. Lamkin says. "You have to have a gatekeeper for this in order to act quickly." The hospital has only 24 hours after admission to change a patient's billing status.
Learn more about Pace Healthcare Consulting.