RAC Assessment Case Study
The Case: Gritman Medical Center, Moscow, ID
The Challenges
Gritman Medical Center’s CEO and his leadership team understood the challenges hospitals nationwide faced with the establishment of a permanent Recovery Audit Contractor (RAC) program. What wasn’t so clear was how their hospital would fair when RAC auditors looked closely at things like medical necessity, one- and two-day stays, use of observation status, and chart documentation. Were the hospital’s clinical directors, physicians and medical staff being as thorough as they needed to be? Were they as educated on the subject of clinical documentation as the RAC program demanded? How could they improve their processes to ensure Gritman’s success in dealing with the RAC?
Q Solutions
Gritman Medical Center’s QHR RAC Assessment focused on:
- Chart review
- Physician documentation
- Education
Over a period of several days, a QHR Senior Consultant Glenn conducted various training sessions for Gritman’s medical staff, including an exclusive meeting with the hospital’s Emergency department physicians. He also provided documentation training to Emergency department staff, Case Management, Medical Records and select department directors.
“The Emergency department physicians gained a better understanding of the importance of documenting why a test is being ordered, or ensuring that a patient meets medical necessity requirements prior to admission,” said CEO Jeff Martin. “Case Management, too, has a better understanding of the medical necessity requirements and when to prompt the physicians to document more specifi cally.
“Our coders now fully understand the need for more queries for specifi cs on a diagnosis, and the need for concurrent review of the in-house records,” he added.
Gritman’s RAC Assessment even went as faras the hospital’s dietician, who learned how to document for gastroparesis due to diabetes and many other disease processes that are not codeable without physician documentation.
The Outcome
- QHR’s RAC Assessment helped Gritman’s physicians recognize the need for collaboration in all RAC initiatives. The training helped them understand how clear processes and diligence in follow-through benefi t both the hospital and the physicians’ businesses.
- Gritman established a review process that ensures that bills can be dropped in a timely fashion, and that when missing documentation becomes available, a record can be re-coded and re-billed, if necessary.
- By preventing denials, Gritman is avoiding the costs associated with the appeal process –about $2000 per appeal, according to the American Hospital Association.
- By preventing denials, Gritman is also avoiding the interest costs associated with appeal denials – 11 percent of the improper payment from the date of the initial denial notice.
“QHR's consultants are incredibly knowledgeable and it showed in our training sessions. They have the ability to target their audience with what they need to know. They were direct and to the point, which was appreciated. Plus, QHR used our own charts and reviews with our staff . By using our charts, we could learn what we were missing or could improve upon via thorough documentation.”
