As we’ve worked with hundreds of hospitals managing RAC audits, we’ve encountered challenges and requirements that are very consistent from one organization to the next. From this experience, we’ve identified the requirements that we believe are critical to achieving success with any Claims Audit solution:

• The RAC solution should enable you to take control of the audit and appeals process -
  The RAC audit and appeals process is very complex and this inherent complexity creates an advantage for the RAC Auditor. A RAC solution should serve as your “Virtual RAC Coordinator” to minimize complexity by automating the process and task assignments, ensuring responsibility and accountability throughout your organization.

• The RAC solution should enable an efficient process -

  Hospitals, like organizations in many other industries, tend to operate in functional silos.   Responding to RAC audit record requests and managing successful appeals requires coordination and cooperation across many departments within the hospital.  For healthcare systems, this may be even more difficult as the process may need to be coordinated across the geography of multiple hospitals.  To ensure accurate, timely responses to record requests and go/no-go decisions on appeals, the RAC solution should provide the structure for coordinating all parties in each department, making sure that responsibilities are clearly understood.  The solution should provide reminders and alerts for individuals, as well as overall status indicators and warnings for the RAC coordinator, to ensure that critical deadlines are met.  By doing so, the solution will help ensure that everyone involved feels accountable for their part in the process.

• The RAC solution should serve as the “Claims Audit System of Record” -
  

  This means several things.  First, serving as a central hub, the RAC solution should be capable of efficiently gathering information from multiple sources.  Within a healthcare organization, these sources of information, such as patient accounting systems, 835 & 837 records, 3rd-party billing systems and others, are often widely varied in nature with little or no pre-existing integration.  The RAC solution should be able to pull all of the needed information together in a cohesive manner to efficiently support record requests and go/no-go decisions on appeals. 
  

  Secondly, the RAC solution should also support other types of medical claims audits such as MIC, MAC, CERT, PERM, MFCU, ZPIC and others, as well as commercial payor audits.  All claims audits pose financial risks for hospitals and the best-practices established to manage RAC audits can be used to reduce the risks of other claims audits as well.  Ideally, the RAC solution should be easily expanded to address other forms of claims audits, without the need for purchasing and installing additional software.

• The RAC solution should be fully implemented rapidly -

  Time is of the essence as hospitals prepare. Hospitals need a comprehensive solution that can be deployed rapidly so they can be fully prepared to respond with confidence as they begin receiving record request letters.



• The RAC solution should provide executive oversight -

  If you can’t measure it and monitor it, you can’t manage it.  Hospital executives need up-to-the-minute visibility into their total financial exposure and other key indicators such as potential missed deadlines.  They also need to see the trends to better understand the vulnerabilities that the RAC auditors are likely to target.  The RAC solution should make this available in a manner that is meaningful and appropriate for each decision maker.  The supporting details should also be readily available so that underlying problems can be identified and corrected.



• The RAC solution should support proactive audit avoidance –

  Most hospitals are scrambling now, preparing to respond to RAC audits and mount their appeals.  Once we are beyond the initial hurdles of the RAC program, hospitals should be able to use their RAC solutions to conduct cost-effective self-assessments and defense audits.  By proactively catching and addressing the most common coding errors and other violations that will be lucrative for the RAC auditors, hospitals can establish barriers that will force the RAC auditors to seek their bounty elsewhere.

Demonstrations of the Compliance 360 Claims Auditor

To learn more about using the Compliance 360 Claims Auditor to manage your RAC audits and appeals we invite you to view a recorded demonstration of the system:

• Compliance 360 Claims Auditor Demonstration
  On-demand web demo

To request a personal demonstration of the Compliance 360 Claims Auditor, please Contact Us.

Free Claims Audit Training (Live and On-Demand Webinars)

You are also invited to attend our live broadcasts or replay our on-demand recorded training webinars at your convenience. These training webinars have been attended by more than 10,000 participants and have received very positive feedback.  Click Here for the full list of live and on-demand training webinars.

Learn More

To learn how leading healthcare providers are using Compliance 360 to minimize their compliance overhead and risks, and how you can be do the same, contact us today.