RAC: Are They Qualified For The Task At Hand?

As discussed prior, the RACs are here to stay.  With the millions of dollars returned to the Medicare program there is certainly no reason for them to go away.  However, who are the individuals reviewing the thousands of medical records from across the nation?  What are their qualifications?  If a provider feels the recovery was improper do they have recourse?

Indeed healthcare has changed.  New industries have emerged to meet the changing demands and RAC are yet another example of that.  Although the news reports the unemployment rate across the nation is at historic levels, this new field offers many opportunities.  What are the qualifications to obtain a position with one of the government contracted RAC providers?

According to RecoveryAuditContrators.org all that is required to obtain a position in this field is an associates or bachelors degree in healthcare, business or finance.  Experience in medical insurance auditing or possessing any of the coding certifications available would be considered a plus.  Do those seem like sufficient qualifications for someone responsible for the review a medical chart?  Clinicians must make decisions, order further testing, or assign diagnosis, based on signs and symptoms as they present themselves; at that moment.  It is only after they have ordered and completed additional testing that they can rule out various conditions or definitively diagnose and treat what was discovered.  Could someone with a background in finance understand these complexities?

Take, for example, this scenario.  A sixty seven year old female presents to the emergency room with epigastric pain.  Gastro esophageal reflux disease (GERD) can create this type of pain or a heart attack can present in this manner.  The physician will attempt to rule out both disease processes.  The patient is found to have GERD, but a heart condition cannot be definitively excluded for this episode. Therefore she is admitted to the hospital for further cardiac testing.

As a result of the additional testing any underlying cardiac disease process is ruled out.  Her episode is diagnosed solely as a result of GERD.  The patient is given a treatment plan for her reflux disease and is discharged from the hospital. A claim is submitted to Medicare and paid.

Three years later, as a result of a records request from a RAC, this encounter is reviewed.  The reviewer, who may or may not have a back ground in healthcare and is paid on a contingency basis, disagrees with the course of treatment ordered by the patient’s physicians.  As a result the payment made to the provider is taken back, indicating the services were not medically necessary.  Is this reviewer qualified to make this determination?  If physician services and decisions are being scrutinized, shouldn’t that scrutiny come from their peers?  Does this reviewer have an unfair incentive to take this payment back?  Is a percentage of recovery appropriate compensation?

The “take payments back and ask questions later” manner in which the RACs operate is at best questionable.  Providers can appeal these decisions and many have been overturned, however, those are costly.  Again, another industry is birthed, physician driven organizations whose purpose is to partner with clinical providers to offer real time guidance for current patient populations and appeal RAC decisions.

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