The National Medicare RAC Summit Washington DC March 5-6 2009

1. Embed the RAC Program in Your Revenue Cycle Process The National Medicare RAC Summit Washington DC March 5-6 2009

2. Adventist Health, Inc. Not-for-profit, faith-based health care system headquartered in Roseville, CA, just east of Sacramento Affiliated with the Seventh-day Adventist Church Carol Richardson, MA, RHIA March 6 2009

3. Adventist Health, Inc. – Roseville, CA • California, Oregon, Washington and Hawaii • 17 hospitals with 2800 beds – 13 in California • 110,188 admissions • 392,495 emergency department visits • 1,969,779 outpatient visits • 22 rural health clinics • 15 home care agencies • Clinics and outpatient facilities • Three joint venture retirement centers (with a 4th on • the way) • 18,000 employees Carol Richardson, MA, RHIA March 6 2009

4. Adventist Health Site Map 1 Corporate Office 2 Adventist Medical Center, Portland 3 Castle Medical Center 4 Central Valley General Hospital 5 Feather River Hospital 6 Glendale Adventist Medical Center 7 Hanford Community Medical Center 8 Howard Memorial Hospital 9 Redbud Community Hospital 10 St. Helena Hospital 11 San Joaquin Community Hospital 12 Selma Community Hospital, Inc. 13 Simi Valley Hospital 14 Sonora Regional Medical Center 15 South Coast Medical Center 16 Tillamook County General Hospital 17 Ukiah Valley Medical Center 18 Walla Walla General Hospital 19 White Memorial Medical Center Carol Richardson, MA, RHIA March 6 2009

5. Our Vision – RAC Demonstration Goal #1 Standardize management of RAC correspondence and payment denials across facilities • Identification • Tracking • Management • Resolution Carol Richardson, MA, RHIA March 6 2009

6. Our Vision – RAC Demonstration Goal #2 Establish coding audit of alleged coding errors and DRG changes • Select external coding vendor to perform all audits • Implement process for facilities to provide data to vendor • RAC correspondence • Coding summary/abstract • Physician coding query • Medical record • UB92 Carol Richardson, MA, RHIA March 6 2009

7. Our Vision – RAC Demonstration Goal #2 Establish coding audit of alleged coding errors and DRG changes • Develop communication tools for vendor, facilities and Corporate • Vendor draft rebuttal correspondence • Vendor and Corporate HIM jointly review audit findings and rebuttal decisions on weekly conference calls Carol Richardson, MA, RHIA March 6 2009

8. Our Vision – RAC Demonstration Goal #3 Deliver coding education on RAC coding risk areas monthly • Vendor develop curriculum including case scenarios • Coder pre- and post-testing • Track with AH/MC Strategies Learning Management System • Issue certificates of attendance • Deliver seminar via WebEx • Archived on Corporate HIM website on AH intranet Carol Richardson, MA, RHIA March 6 2009

9. Coder Education Seminars 2006 • 04/06 – DRG 397, Coagulation Disorders • 05/06 – DRG 217, Wound Debridement • 06/06 – DRG 416, Septicemia • 07/06 – DRG 468, Operating Procedure Not Related to Diagnosis • 08/06 – DRG 124, Circulation Disorder • 10/06 – DRG 478, Other Vascular Procedures • 11/06 – DRG 475, Respiratory Diagnosis with Ventilator Support • 12/06 – DRG 148, Major Small and Large Bowel Procedures Carol Richardson, MA, RHIA March 6 2009

10. Coder Education Seminars 2007 • 01/07 – DRG 76, Other Respiratory System Operating Room Procedures • 01/07 – DRG 82, Respiratory Neoplasms • 02/07 – DRG 141, Syncope and Collapse • 03/07 – Principal Diagnoses with Complications & Comorbidities • 04/07 – Principal Diagnoses with Complications & Comorbidities Case Studies Carol Richardson, MA, RHIA March 6 2009

11. Coder Education Seminars2007 (continued) • 06/07 – DRG 193, Hepatobiliary Tract Procedure • 07/07 – Operative Report Coding • 08/07 – DRG 144, Other Circulatory System Diagnoses with Complications and Comorbidities • 09/07 – DRG 415, Infections and Parasites • 11/07 – DRG 174, Gastrointestinal Hemorrhage with Complications and Comorbidities • 12/07 – DRG 296, Nutritional/Miscellaneous Metabolic Disorders Carol Richardson, MA, RHIA March 6 2009

12. Coder Education Seminars 2008 • 01/08 – MS-DRGs 190/191/192, COPD • 02/08 – MS-DRGs 291/292/293, Heart Failure and Shock • 03/08 – MS-DRGs 299/300/301, Peripheral Vascular Disease w CC • 04/08 – MS-DRGs 579/580/581, Other Skin Subcu Tissue & Breast Procedures • 05/08 – MS-DRGs 602/603, Cellulitis >17 yrs. w/o CC • 06/08 – MS-DRGs 193/194/195 Simple Pneumonia & Pleurisy w/o CC Carol Richardson, MA, RHIA March 6 2009

13. Our Vision – RAC Demonstration Goal #4 Implement system-wide RAC activity reporting tool • Locate on system intranet • Provide data entry access for facility • RAC Coordinators • Directors, Patient Financial Services • Capture 100% of RAC correspondence • Provide view access for facility and corporate administration Carol Richardson, MA, RHIA March 6 2009

14. Our Vision for the Data Base Auto-populate data • Enter account number, From claims file,  • Medical record number • DRG • Discharge date • Coder ID • Enter account number, From DRG tables specific to facility and year • DRG weight • DRG payment • Enter account number, From remittance advice file,  • Date recouped • Dollars recouped Carol Richardson, MA, RHIA March 6 2009

15. Our Vision – RAC Demonstration Goal #4 Implement system-wide RAC activity reporting tool • Data aggregation by facility and across system Carol Richardson, MA, RHIA March 6 2009

16. Carol Richardson, MA, RHIA March 6 2009

17. Carol Richardson, MA, RHIA March 6 2009

18. Carol Richardson, MA, RHIA March 6 2009

19. Carol Richardson, MA, RHIA March 6 2009

20. Taking Advantage of the RAC Pause Enterprise Government Payer Data Base • AH RAC Tracker • Refine data fields • Expand reporting functionality • Retrain workforce • OR? • Better mousetrap • Internal IT expense to bring internal data base up to speed vs. expense of commercial product Carol Richardson, MA, RHIA March 6 2009

21. Taking Advantage of the RAC Pause Roll out standard, corporate policy and process for RAC management • Facility Revenue Cycle Committee will monitor and direct RAC activity as a standard agenda item • Facilities will adopt best practices in RAC management Carol Richardson, MA, RHIA March 6 2009

22. Taking Advantage of the RAC Pause Standard Enterprise RAC Policy • Identifies key stakeholders • Chief Financial Officer • HIM Director • Patient Financial Services Director • Case Management Director • Ancillary Department Directors • Requires designation of Corporate & facility RAC Coordinators Carol Richardson, MA, RHIA March 6 2009

23. Taking Advantage of the RAC Pause • Standard Enterprise RAC Policy • Requires Facility & Corporate Revenue Cycle Committees to oversee RAC process • RAC data base • Correspondence, rebuttal and appeal workflow • Denial-type action plans • Staff education • State/Regional hospital association RAC user groups Carol Richardson, MA, RHIA March 6 2009

24. Enterprise Govt Payer Audit Data Base Corporate Revenue Cycle Committee Corporate RAC Coordinator Facility Revenue Cycle Committee Chief Financial Officer Case Management Director PFS Director HIM Director Ancillary Department Directors Facility RAC Coordinator Carol Richardson, MA, RHIA March 6 2009

25. RAC Best Practices Talk to Providers in the Demonstration Project • Vendors and consultants know some things, but not all things Do your homework • “The Medicare Recovery Audit Contractor (RAC) Program – An Evaluation of the 3-Year Demonstration – June 2008” http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf • “Statement of Work for the Recovery Audit Contractor Program November 7, 2007” https://www.fbo.gov/download/f8f/f8f1d845d960c3229301aeec334c7eb4/2_J-1RACSOW11-5-07VS2(3).doc Carol Richardson, MA, RHIA March 6 2009

26. RAC Best Practices Budget for • RAC management FTE • Outsourced Coding and Medical Necessity review • Coder and Case Management education • Adequate Release of Information manhours in HIM • Counsel support in Formal Medicare Appeal Process Carol Richardson, MA, RHIA March 6 2009

27. RAC Best Practices • Re-Evaluate your Release of Information Solution • How tight is the current turnaround? • What accuracy rate is reported by your Quality Control process? • Internal vs. Outsourced? • If you outsource, consider a penalty against the invoice for any late or inaccurate RAC response • If you’re considering outsourcing, some vendors are able to incorporate document imaging which supports the rebuttal and appeal process • Track every piece of RAC Correspondence • Name and empower the RAC Coordinator position • Direct Revenue Cycle Committee to monitor RAC activity Carol Richardson, MA, RHIA March 6 2009

28. RAC Best Practices • Require all Coders to be Credentialed • Outsource Coding and Case Management audit • Tighten Up Coding Vendor Contracts • Add penalty against invoice for retroactive payment denials • Tighten Up & Expand Physician Coding Query Process • Require that physicians be queried per AHIMA guidelines • Track and monitor query trends by physician, code/DRG and coder • Add pending queries to Medical Staff Bylaws, Rules and Regulations definition of incomplete/delinquent medical record Carol Richardson, MA, RHIA March 6 2009

29. RAC Best Practices • Meet every deadline - NO TECHNICAL DENIALS! • Send ALL the RIGHT stuff the FIRST time • Hold the RAC accountable • Processes • Timelines as defined by CMS • Communication Carol Richardson, MA, RHIA March 6 2009

30. RAC Best Practices • Rebut initial RAC decisions as appropriate • Pursue formal Medicare appeals as appropriate • Educate • Coders • Case Managers/Utilization Review • Network with and through hospital association Carol Richardson, MA, RHIA March 6 2009

31. Carol Richardson, MA, RHIA Corporate Director, Health Information Management Adventist Health, Inc. 2100 Douglas Boulevard Roseville, California 95661 916-774-3369 RicharCF@ah.org Carol Richardson, MA, RHIA March 6 2009