RAC auditors tell it like it is

July 21, 2016 ABILITY

In April, ABILITY Network acquired eHealth Data Solutions (eHDS), a software company offering tools for long-term/post-acute care providers that increase quality, reduce risk and create higher value and cost-effective resident-centered care. We’re pleased to share a series of blog posts recapping the recent CONNECT 2016 conference, co-hosted by eHDS and ABILITY.  

Inconsistencies and incongruences are the hallmarks of an audit waiting to happen, according to two former recovery audit contractor (RAC) auditors, who presented at the recent CONNECT 2016 conference in Chicago during a session titled “Confessions of a RAC Auditor.”

These insights are especially valuable for SNFs because they provide highly useful advice and real-life examples of what RAC auditors are looking for in your organization’s documentation. Remember, a RAC auditor can only look at what CMS has approved as an audit topic.

Led by two former RAC auditors, the session featured highlights from their collective knowledge and experience working for contractors that conducted frequent audits of nursing home records. Their message was loud and clear: Auditors find numerous red flags that are missed by staff.

Here are some additional takeaways from the session:

  1. In many cases, the auditors get your minimum data set (MDS), and staff may have completed the MDS even before the documentation in the EMR for that patient on the MDS is complete. This makes it easier for the auditor to track your mistakes. The MDS will have reported information that is contradicted by the EMR.
  2. It’s important to check and scrub MDS submissions for inconsistencies, advised Michelle Karl, LVN, BSHA, RAC-CT, who said, “I’ve seen contradictions that say a resident was in isolation, but then walking the corridor. You should always look at the ADL documentation for that day.”
  3. Remember that a RAC auditor’s job is to validate the facility’s reimbursement piece. In fact, many auditors must do 20 audits per day. And they are looking for documentation to validate your reimbursement.
  4. You may be surprised to know that some nursing home staff forget to do a discharge assessment. This is a big problem, the presenters said, because it puts the reimbursement for that resident’s entire stay at risk. “With no discharge assessment, the RAC auditor will appropriately default the entire stay,” Karl told session attendees.
  5. Having many of your residents categorized as ultra-high RUAs on the 5-day MDS assessment sends up a red flag to auditors. In addition, if your residents in this category don’t appear to be getting help with ADLs, auditors will flag that as well.
  6. Once you do poorly in audits, you are marked, and the next time around they may take a deeper look at you. Conversely, if you do well, they will be more hands-off the next time around.

How do you avoid getting audited—or worse yet—getting dinged for an inconsistency? In addition to the whole organization working together with key personnel to achieve accurate documentation and MDS coding, implement a triple check, the session presenters urged. An effective triple check should include the following three key people: rehab department manager, MDS nurse, and the business office manager.

Ultimately, education is key to ensuring consistency and congruency in your documentation. Therefore, be sure to educate and train effectively and as often as possible.

By taking the time to check, train, and educate your staff around your MDS documentation, you will be rewarded not only with effective and timely reimbursement, but also with the knowledge that it is appropriate.


To learn more about how ABILITY Network can help you protect against fraud and ensure your documentation supports the care you provide, contact us. 



The post RAC Auditors Tell It Like It Is appeared first on ABILITY Website.


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