EHC’s focus on correct admission status combats RAC risks
Management of resource utilization is a continuous challenge all providers face in today's dynamic health care environment. This challenge is compounded by increased pressures from government and payors regarding:
- Extended lengths of stay
- Payment denials for avoidable days and inappropriate admission status
- Compliance with Medicare Conditions of Participation
In addition, the Recovery Audit Contractor (RAC) program is now being implemented in all 50 states because Medicare believes billions of dollars in past payments to doctors and hospitals were incorrect and lacked medical necessity. The initial RAC demonstration project in five states identified more than $1.03 billion in improper Medicare payments as of March 2008 - 96 percent were overpayments collected from providers.
Action plan
The best way to minimize the likelihood of denials and avoid recovery of alleged overpayments is through a comprehensive approach that focuses on:
- Improving medical management
- Coordinating of care
- Providing correct patient status from point of entry
- Communicating among all members of the care delivery team
First line of defense
Utilization Review is the first line of defense in this battle, but those efforts need to be supported by experienced physicians who can both facilitate solutions for physicians and deal with the payors regarding justification of appropriate payments for services rendered to patients. In order to fortify this strategy, EHC has implemented a program in collaboration with Executive Health Resources (EHR), a physician-operated organization that provides secondary physician advisor support to acute care hospitals throughout the country. EHR has been extremely successful in assisting facilities with ensuring correct patient billing status and overturning denials.
Benefits
A primary objective of the program is to ensure services are rendered at the appropriate level of care. The benefits of this program, which can only succeed with provider support, include:
- Providers and the hospital can be in compliance with the law while maintaining revenue integrity.
- The Inpatient vs. Observation decision-making hassle does not fall solely on the provider (EHR Physician Advisors help manage the process).
- Providers can ensure that they have written the correct order (Inpatient vs. Observation) based on the agreed-upon appropriate admission status.
- Providers can avoid inappropriate financial responsibility for their patients for the care they have received from individual providers and the hospital.
Utilization Review began working with the EHR physicians on Tuesday, January 19, 2010. You may begin to receive calls from EHR to discuss cases selected for review, although we anticipate this volume to be less than 25 percent of the cases referred to EHR. The program places a strong emphasis on interacting with attending physicians in a positive and collaborative manner as their intimate clinical knowledge of the patient provides critical information to the EHR Physician Advisors.
How can you help?
- Be aware of the EHR program.
- Be available to speak with EHR physicians when asked to do so.
We appreciate your support and your willingness to review cases, when necessary, with the EHR Physician Advisors.
For questions or further information, please contact Bryce Gartland, MD, medical director of Care Coordination and director of Hospital Medicine, Emory University Hospital, at 404-712-3834 or Val Akopov, MD, FHM, medical director of Care Coordination, Emory University Hospital Midtown, at 404-686-2691.
