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If I Were a Recovery Audit Contractor


If I were a Recovery Audit Contractor, I know pretty much exactly how I would choose my targets for review. After all, we know that that the RACs can use statistical information from electronic sources to select agencies to review. By looking at aberrancies in data, I would choose the following triggers to guide me in my work:

  1. High case mix weights. This is pretty much a given since agencies with very low case mix weights may be under-billing.
  2. High therapy utilization. Nothing brings up a case mix weight more than therapy! Prior to 2008, there were many patients who needed 10 or 11 visits to meet the therapy threshold. Now the same patient might be assessed as needing seven or 14 visits! Very few patients receive 12 visits anymore.
  3. I would look for a lot of technical stuff. If I wanted to prove a diagnosis wasn’t appropriate, I would have a lot of clinical record review to get through. Then, when I adjusted the case mix weight based on diagnosis coding, I might find a couple of hundred dollars. On the other hand, if a physician didn’t date his or her signature, I get back the entire HHRG.
  4. All things being equal, I would choose agencies with very long lengths of stay. While it is true that a Medicare Beneficiary is entitled to unlimited episodes of home health as long as they have a qualifying need, documentation tends to become stale after a while. Homebound status is a little more difficult to discern by clinical record review but when I am reviewing clinical records, I can’t help but wonder about patients with multiple missed visit reports.

Does this mean that you should avoid patients who need therapy and have a high case mix weight. I do not see that as a valid answer. But when time is limited and you must pick and choose clinical records to review for completeness, these are the types of patients I would choose. I would also keep all these factors in mind at case conference. Front end protection in a RAC situation is most certainly better than trying to address problems after the record has been requested.

If you have comments or questions, please post below or email them. If you have any other ideas of what you would do if you were a RAC auditor, please share!

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