As a fan of the sport of ice hockey, tonight will mark a special moment. The Stanley Cup Finals will have a 7th and final game in Vancouver, British Columbia to decide this year’s champion. This will mark only the 16th time in NHL history that this has occurred.

One of the oldest cliches in sports is that playing in a Game 7 in hockey, baseball or basketball is the contest in which every young boy dreams of competing. Tonight, when I watch the introduction to the latest Game 7, which will more than likely include clips of plays from the previous 6 games, music that begins with one lonely French Horn playing a call to arms, and a voice-over talking about dreams and combat, I shall think about the part that’s always left out of this particular tale of sporting romance. To put it specifically, in order for a Game 7 to happen, your team has to lose three games in the series. Knowing this makes the lead-in less that dream-like.

Thanks to the RAC process, providers are finding out the hard way what it means to lose before winning. According to the latest AHA RACTrac survey, successful provider appeal rates remain unusually high as the RACs approach their second anniversary on October 1st of this year. Thirty-eight percent of hospitals participating in the latest quarterly survey stated that they had at least one claim overturned in the RAC discussion period. Further, 68% of hospitals reported filing at least one appeal and 71% of completed appeals have been found in favor of the provider.

While it can be seen as a positive that the RACs are on a learning curve, and that their first claim determinations have a way of not sticking, these facts do not necessarily mean that affected providers are coming out completely victorious. The administrative costs of responding to additional documentation requests can be prohibitive. The recognized reimbursement rate under the RAC program of 12 cents per page of medical records comes nowhere close to reimbursing the staff hours and supply costs expended for ADR response. Factor in the costs of determining (and subsequently preparing) appeals, and suddenly that 12 cents per page rate feels insulting.

If I were to give one piece of advice to providers, it is to beware of retrofitting the RAC response process into the existing correspondence infrastructures of the office or facility and assuming that everything is going to work perfectly. Because of the time lines involved, identifying and acting on RAC correspondence is an important step is establishing reasons for appeal later in the process. Most facilities have responded to the RAC threat by appointing RAC coordinators to manage the process, but this act alone does not insure timeline compliance. In most cases, the RAC coordinator is selected more for their auditing and compliance skill sets than any demonstrated acumen with correspondence. 

Any team builds toward victory by learning to adjust to the opponent. In the case of RAC contractors, they are big, unwieldy and not particularly organized, but I would add “yet”. Facilities are currently on the losing end because of the administrative burden and the RAC audits that have actually recovered funds, but continuing refinement of the RAC process, with a second eye pointed in the direction of clinical documentation improvement. In the Stanley Cup Finals of RAC preparedness, the facilities are in the second period of game two, down by a couple of goals and trailing in the series 1-0. Playing in Game 7 is the easy part. Arriving healthy in the arena for that game is the fight of a lifetime.

Tags: correspondence / Game 7 / RAC / Recovery Audit Contractors / Stanley Cup Finals / workflow
11:27 am, June 15th, 2011 |