Guest Columns

Fuzzy math in RAC audits

Tara Roberts
Tara Roberts

If you are like me and have children who are required to contribute to science fairs yearly then you understand that the method in a science project is as important as the topic. It's about those “little” details like controlling variables, accounting for all possibilities, maybe even using real math. It is difficult to explain to my children this importance when they hear me talk about my industry and agencies that “audit,” and how these agencies freely manipulate or ignore data to derive results they want versus results that are real.

In recent months we learned how “effective” the RAC program was in saving the Centers for Medicare & Medicaid Services billions of dollars. Specifically a couple of million, just from long-term care. Then came the praise from The American Coalition for Healthcare Claims Integrity stating the RAC determinations are accurate more than 95% of the time.

If you are like me, reading that claim caused a rise in your blood pressure. 

Not only am I confused by their assessment, hence my title of “Fuzzy Math,” but I am also quite confused by an organization whose name has the word INTEGRITY in it coming to such a conclusion. Integrity includes the concepts of consistency of actions, values, methods (there is that science word again), measures, principles, expectations, and morals. Reporting on RAC success rates without having a functioning appeals process that is active, compliant, accountable and validated is irresponsible. It is dangerous and without rebuttal or a demand for factual non-fuzzy math, LTC can expect a darkening black eye.

Fast forward a few months and RAC audit resumption is just a sunrise and cup of coffee away. Some RAC resumption plans will potentially include audit frequency and intensity based on a provider's denial rates otherwise known as RAC successes or “fuzzy math.”  While having parameters to target claims for review isn't a bad idea, using “fuzzy math” to determine rankings and denial rates of providers for those targets is absurd. It potentially sets up providers, who, keep in mind, will eventually achieve great success with an Administrative Law Judge, for unnecessary review, negative beneficiary impact and excessive administrative and financial burdens. 

My sunrise and coffee were a lot more enjoyable this week when I read about the American Medical Association's recommendations for RAC accountability in recent days.  The AMA is not messing around with “fuzzy math.” RACs + Incorrect Claim Accusations = RAC Penalties.  Now that is something even my children can understand.

I leave you with a parody of a familiar children's poem…

Fuzzy Wuzzy was a RAC

Fuzzy Wuzzy was incorrect!

Fuzzy Wuzzy felt dismay

Because Fuzzy Wuzzy had to pay!

So math that is Fuzzy

No longer benefited Wuzzy

And we may

Need to thank the AMA!

Tara Roberts, PT, is the Vice President of Rehabilitation and Wound Care Services at Nexion Health.

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