For today’s look at Recovery Audit Contractors, I thought I’d start with some essential truths about the RAC’s and their function.
I see RAC’s as golems. While the four regional RAC’s are now self-sufficient, they are a creation borne out of a recognized need to control dollars paid from the Medicare and Medicaid programs. They are given their shape by Medicare’s proprietary software and as an extension of limited investigations, either by the OIG or the Medicare Administrative Carriers (MAC’s), that have already been completed. In other words, the creator starts small with a scale model of an audit, followed by their man-made, unfeeling behemoth that is the RAC bringing down their earthen fist and smiting everything in its path of a similar nature. The current appeals success rate for RAC determinations strongly indicates that the golems do so indiscriminately, without an instinctive need to be correct.
In anticipation of the inevitable RAC investigational expansion into physician services, experts in the industry have trained their attentions on the Comprehensive Error Rate Testing (CERT) Reports. These reports are a good indicator of what services require additional investigation, but there are a few stops in between a CERT and a RAC that further narrow the focus of the eventual RAC investigation. A quick review of my inbox this morning revealed one of these interim studies, the results of which illuminate the world of RAC audits like an H-bomb test on Bikini Atoll.
WPS, the current MAC for Jurisdiction 5 (covering Iowa, Kansas, Missouri and Nebraska) and the legacy MAC for Illinois, Michigan, Minnesota and Wisconsin, released the results of a Service Specific Probe of CPT code 99214 for the specialty of Family Practice this past Monday. 100 such services were randomly selected for prepayment review. Of these, 52 were allowed as billed following documentation review. Based on the utilization of this code, that number seems low. With the belief that we learn from our mistakes, I now present the results of the remaining 48 claims.
11 claims were down-coded based on the documentation provided. To review, a level 4 established patient visit requires that two of the following three elements be satisfied by the documentation:
- Detailed history
- Detailed examination
- Moderate medical decision making
While not specifically stated in the CMS E/M guidelines, with established visits, it is always a good idea to have medical decision making be one of the two elements selected. I recommend this based on medical necessity most often being defined based on treatment options selected for the condition being treated. Even in a patient with a list of comorbidities written on a 3-foot scroll, if a patient has a bit of a rash, the greatest history ever taken and an examination and auscultation of every square inch of a patient is still treating a bit of a rash, and the E/M code selection needs to reflect this.
2 of the claims in the study were determined not to support the billing of an E/M service based on the documentation forwarded for the study. If I had to venture a guess, I would say that these were related to encounters where a minor procedure was planned upon scheduling, the patient presented for the procedure, and the physicians in question billed both a procedure and an E/M service.
The remaining 35 claims represent a different kind of hurdle for physician practices. These claims were denied outright because the providers did not provide the requested documentation for the services within the alloted 45-day period. This study included only 100 claims. If we expand that number out by a few zeroes, apply it to RAC documentation requests and then extrapolate that 35% of these requests will either be mishandled or ignored, the obvious conclusion is that by virtue of their internal practices, physicians are doing the RAC’s work for them. Who knew doctors had this kind of time on their hands?
Part A providers knew the RAC’s were coming, and any facility worth its salt set up processes long ago to respond to RAC requests. It is my personal belief that a connection can be made between provider readiness for RAC audit requests and the so-far successful appeal rate of RAC decisions by Part A providers. A physician practice, in most cases, lacks the organizational infrastructure to prepare to respond in the same way as Part A providers. A solution to response readiness is not – and in many ways, cannot be - a one-size fits-all proposition. A good start would be educating administrative staff to be able to recognize a RAC request upon receipt.
With a 48% error rate in this limited probe, it is safe to say that high level established patient visits are now officially warming up in the RAC bullpen. A surprise occurs when you never see it coming. Like the relief pitcher who replaces the obviously tired starter, we saw them warming up. The RAC’s, in the same manner as the next pitcher jogging in from the outfield, is easy to see. In fact, based on their size, so are most golems.