1. Surviving the RAC
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increasing wealt h by managing risk

2. The Goal

3. The Goal
• Hakunamattata

4. The Goal
• Hakunamattata
• Maximize revenue

5. The Goal
• Hakunamattata
• Maximize revenue
• Minimize compliance costs

6. History
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increasing wealt h by managing risk

7. History
2003
‣ Detect
‣ Correct
‣ Collect
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8. History
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9. History
2005
‣ 3 year demonstration
‣ 3 states
‣ $1.03 billion
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10. History
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11. History
2006
‣ Tax Relief and Healthcare Act
‣ Nationwide RAC by 2010
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12. Meet the RACs
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13. Meet the RACs
HealthDataInsights Inc. Diversified Collection Services
CGI Technologies and Solutions
Connolly Consulting Inc. -
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increasing wealt h by managing risk

14. No Provider is Immune
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15. No Provider is Immune
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16. What Does a RAC Do?
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17. Automated Reviews
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18. Automated Reviews
‣ Data mining
‣ Primarily outpatient
services
‣ No medical record review
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19. Complex Reviews
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20. Complex Reviews
‣ Medical record requests
‣ 45 days to submit charts
‣ waive right to appeal if
late
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21. CMS Focus
‣ Medical necessity
‣ Proper coding
‣ Sufficient documentation
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22. 2009
Records Limits

23. 2009
Records Limits
‣ Sole Practitioner
‣ 10 per 45 days per NPI
‣ Partnership 2-5 individuals
‣ 20 per 45 days per NPI
‣ Large Group 16+ individuals
‣ 50 per 45 days per NPI

24. Post Review Notice
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25. Post Review Notice
‣ Decision sent within 60 days
of receipt
‣ “Demand Letters” sent with
reason for determination
‣ RAC advises of right of
appeal
‣ RAC will not assist with the
appeals process
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26. 30 41
Extended
Pay Recoup
Pay
Pay/ Recoup Extended
Appeal Pay
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27. 11%!
30 41
Extended
Pay Recoup
Pay
Pay/ Recoup Extended
Appeal Pay
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increasing wealt h by managing risk

28. The Collector
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29. And Then?
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30. And Then?
The process can be repeated
every 45 days....!
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31. Guess who’s next?
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32. Guess who’s next?
‣ Mic’s (Medical Integrity
Contractors)
‣ Commercial carriers
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33. -
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34. An investment in compliance oversight is like
homeowners insurance. The risk it may be
needed could be low, but going without could
be catastrophic.
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increasing wealt h by managing risk

35. -
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36. "....the cost to the practice of retrieving
the corresponding record and
forwarding the information could be
10X the amount (of overpayments).... "
American Medical Newsamednews.com (7/08)
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37. CMS Recommends
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38. CMS Recommends
‣ Conduct audits
‣ Determine and monitor
your error rate
‣ Stay current with RAC
issues
‣ Prepare response system
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40. The Compliance Review
1
Result: Direction
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41. The Baseline Discovery
2
Result: Clarity
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42. The Code Optimizer
3
Result: Confidence
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43. The RAC Responder
4
Result: Delivery
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44. - your risk
know
RAC Calculator ™
Billings
x
Error Rate
x
Time (yrs)
=
Total
÷ 220
Per Diem
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kome di x
increasing wealt h by managing risk

45. - your risk
know
RAC Calculator ™
Billings $300,000
x
Error Rate
x
Time (yrs)
=
Total
÷ 220
Per Diem
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kome di x
increasing wealt h by managing risk

46. - your risk
know
RAC Calculator ™
Billings $300,000
x
Error Rate
25%
x
Time (yrs)
=
Total
÷ 220
Per Diem
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kome di x
increasing wealt h by managing risk

47. - your risk
know
RAC Calculator ™
Billings $300,000
x
Error Rate
25%
x
Time (yrs)
3
=
Total
÷ 220
Per Diem
-
kome di x
increasing wealt h by managing risk

48. - your risk
know
RAC Calculator ™
Billings $300,000
x
Error Rate
25%
x
Time (yrs)
3
=
Total
$225,000
÷ 220
Per Diem
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increasing wealt h by managing risk

49. - your risk?
Do you know

50. - your risk?
Do you know
‣ Sample size: over 100 audits

51. - your risk?
Do you know
‣ Sample size: over 100 audits
‣ Average error rates: 25% - 35%

52. - your risk?
Do you know
‣ Sample size: over 100 audits
‣ Average error rates: 25% - 35%
‣ Range: 15% - 56%

53. Reduce Your Risk
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increasing wealt h by managing risk

54. Reduce Your Risk
Error Rate
with DRP
Potential
Risk $
Time
without DRP
with DRP
Potential
Risk $
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55. -
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56. -
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57. "....it is more cost-efficient to be proactive
in developing an effective compliance
program than responding to a compliance request
without having adequate compliance
processes in place."
Patient Protection and Affordable Care Act
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58. -
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http://www.komedix.net/knowledge-center/
komedix.net
210.301.0650