2nd Article in RACS Series!

RACS and Case Management: Medicare Patients Can’t Be Pushed to the Bottom of your Priority List Anymore

August 15, 2008
By Randi Ferrare
for the Arizona Case Management Blog

If your hospital is as typical as the majority of the hospitals across the country, your Case Management department may be engaged in the preparation for RACS because of your involvement in the appeal process. However, if this is the only role your organization thinks Case Management can play, that could cost your organization millions of dollars.

During the 3 year RAC demonstration project, CMS had an overwhelming 40-45% denial rate. 99% of those denials were categorized as either services that could have been rendered in an outpatient setting or the inpatient stay was not medically necessary. When it came down to it: the denials were for unnecessary hospitalizations.

Unlike the demonstration project in Florida, New York and California, the new yet-to-be released CMS RAC contract will have a provision that the RAC is only allowed to ask for medical records for patients that had an admit date of October 2007 or later. This creates an opportunity to do a stellar job concurrently while the patients are still in-house.

Case Management needs to treat Medicare as they do managed care. The days of reviewing Medicare charts every three days are gone. Chart review should occur every day, along with making sure that the patient’s care is progressing and moving toward discharge.

So considering that fact, you are probably saying, “Our caseloads are too high to manage that work”. You are probably correct; most Case Management departments across the country are grossly understaffed, sometime with caseloads as high as 40 -45 patients per Case Manager. Not only does that effect job satisfaction and departmental turnover, but it greatly impacts LOS, denials, and patient throughput. All of these key indicators are vitally important to the financial health of the hospital.

You don’t have to be a rocket scientist to realize that you need staff and internal processes that will be able to handle the additional duties and workload that a RAC audits brings.

So, now what? Well, the first step is to engage your immediate supervisor, CFO, CEO - basically anyone that can assist you in hiring enough Case Managers to get their caseloads to a more manageable level of 15-20 cases per manager.

How do you do that? Educate upper management and provide a cost benefit analysis to them that substantiates your need for more staff.