RAC of Lamb
Rack noun (1) \ ˈrak \ Definition of rack (Entry 1 of 9) 1 : a framework, stand, or grating on or in which articles are placed 2 : an instrument of torture on which a body is stretched 3a(1) : a cause of anguish or pain (2) : acute suffering b : the action of straining or wrenching
RAC abbreviation(1) \ ˈrak \ Definition of rac (Entry 1 of 9) 1 : the Recovery Audit Contractor, or RAC, was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans
like a lamb to the slaughter idiom \: 1. In a very innocent way : without knowing that something bad will happen 2: From the Bible, Jeremiah 11:19: But I was like a gentle lamb led to the slaughter; And I did not know that they had devised plots against me, {saying,} “Let us destroy the tree with its fruit, And let us cut him off from the land of the living.”
Definition of bounty hunter 1 : one who tracks down and captures outlaws for whom a reward is offered 2 : one who hunts predatory animals for the reward offered
Many of you have heard of the RAC (Recovery Audit Commission), but some may not. It is Medicare’s policing network. Since it does not have a substantive enough manpower to review and enforce its own policies and procedures, it hires subcontractors to do this work. Specifically the RAC program is intended to recover money paid out improperly. That is a good and praiseworthy plan. We all know there is fraud and overcharging, and it must stop.
Another fact is that all the RAC’s – there are 5 regions of the country, each with a different RAC – make their money like a bounty hunter. They are paid a percentage of the money they recover so they have an incentive to find a lot of fraud and waste. They also have an appeals process, and the RAC does the appeal. Thus they have a strong financial incentive to decide the appeals siding with CMS over the provider. For true fraud that is probably OK for most of us, but a concern when the RAC looks at areas that surprise us and don’t seem to be fraud as we understand the term.
Now the RAC has been given a new charge by CMS (parent of Medicare) – to find Observation stays that should be denied. What that means is CMS will not pay (that is not pay anything at all) for Observation stays where they determine that the care did not need to be provided in the hospital environment. All the medications, IV’s, MRI’s, endoscopies, CT scans, nursing care, X-rays, food, room cleaning, and the rest of the panoply of fixed and variable cost services provided to such patients will be given away for free. Better than any Black Friday sale for the patient but potentially a slow exsanguination for hospitals targeted and found to be using Observation inappropriately.
Here we have 2 conflicts. First, we have custom and practice that is long established – when in doubt use the hospital for a “safety net” for marginal patients for whom we don’t have an easy and comfortable alternative. That directly conflicts with the rapid evolution to value based care – no one should be in a hospital as a patient unless that is the only/best setting for them based on the acuity of their medical situation. Healthcare waste is so extraordinary that this confrontation is not going to go away any time soon.
There is also a conflict of the pen. Many of the patients who get denied probably belong in the hospital, specifically to be an Observation patient in this example, and the hospital should be paid an Observation rate for the stay. As an aside, even this is a pittance of what “should” be paid via a DRG for the same patient if they were “admitted”, as these patients usually were a short time ago. But we see that inadequate documentation conflicts with the requirements for these criteria. If it wasn’t written the right way, the care is deemed unnecessary. When that occurs payment has been/will be/should be denied because we can’t support it with what is written in the chart. This conflict is unsustainable, intolerable, and eminently resolvable.
Proper documentation is akin to writing in a foreign language. We don’t expect all hospital providers to learn new languages and accomplish them fluently. Likewise we can’t and don’t expect any providers to know, understand or agree with any of the rules of documentation. But they are rules, they do exist, and they are not going away. So instead of asking doctors to learn these new coding and documentation languages, we have interpreters available at all times who will guide us. We need to use them and rely on them. There is no other option except to take responsibility directly for the losses when the translators are bypassed and we try and write in the new language of healthcare documentation alone ignoring or not soliciting the guidance – translation – that is now needed.
Is this Armageddon? I think not. You may disagree. But it is a sea change and we need to learn the new rules and adapt so we do not get crushed by the bounty hunters. For now we have 2 learnings: 1. Focus on getting everyone out of our buildings who does not absolutely belong there – big change. 2. Rely completely on CDI, Case Management and our other interpreters to be the saviors who guide us how best to translate our clinical concept into the language of healthcare. Just these 2 powerful forces alone will allow us to survive the next big change that is coming. And it’s coming fast.
