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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, April 24, 2012 Posted in: Inpatient Rehab

If you need to educate staff about the importance of documentation and protecting hard earned revenue, you need to look no farther than an excellent resource provided by the Medicare Learning Network  entitled ‘Contractor Entities At a Glance,’ this comprehensive chart provides entity name, definitions and responsibilities along with the reasons those particular agencies may contact you.  In a few short pages it imparts knowledge to staff that yes, everyone, is looking over our shoulders and these are just the governmental type. Compound this with audits done by other payers and there is a host of reasons why very specific documentation and rules must be followed.

Healthcare is a severely complicated business. Most businesses are concerned with revenue generation and a now and again a ‘money back’ guarantee they offer that may take back their hard earned service cash flow. In healthcare, money back despite all services rendered is more real than ever.   In the fiscal year of 10/1/2010 through 9/30/2011, posted corrections of greater than 900 million were found. In fact, in the fourth quarter alone over-payments accounted for 78% of the corrections.  The odds are NOT in your favor as to whether over or under payments are of your greatest concern.


If you had linked to the flyer above, you’ll see there are more than a dozen more contractor types just as eager to assist us in getting it right!  Most importantly, you have to know that you actually understand the interpretations and that your staff also are well aware and following expected protocol.  Internal audits are key, but more importantly electronic documentation and systems guidance is the better way to go when it helps to discover, alert and help mitigate the thousands of items that must be cross checked day after day.  There are far too many items for staff to keep their finger on the pulse of each one of them.

Who is your assigned Recovery Audit Contractor (RAC), and what issues are presently under review? Acute care has the greatest number approved for review; inpatient rehabilitation and outpatient services can be found through search engine or by provider type sorting.  Utilize these web resources to determine areas of vulnerability, create appropriate teaching opportunities, increase utilization review activity and appropriate safeguards so that your facility isn’t caught up in ‘money back’ negative cash flows.

 RAC Website Issues Under Review
Region A:Diversified Collection ServicesStates: CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI and VT. search engine but can sort by provider type for the 52 pages of items being tracked.  Note: OP Hospital items posted such as, CCI edit, MUE, untimed codes.  Check often for IRF/IRU posted approvals for this region.
Region B: CGIStates: IL, IN, KY, MI, MN, OH and WI. Box provided
20 pages of listed items.  IRF/IRU tracking includes late submission of IRF PAI.
Region C:Connolly, Inc.States: AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico and U.S. Virgin Islands. Search Box provided
51 pages of listed CMS approved audit issues.
Medical Necessity for IRF admission is presently being reviewed in this region.  Click on the link and become familiar with the 5 listed items stated to determine how charting must stand up for validation.
Region D:HealthDataInsightsStates: AK, AZ, CA, HI, ID, IA, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas. No Search engine.  Sort by provider type to review 23 pages of ‘new issues’ posted.  Specific to IRF/IRU are three items of concern.  Late submission of the IRF PAI, Incorrect D/C status on the UB resulting in wrong payment, Medical Necessity of IRF care.


See how Mediware can help prepare you for an audit.
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