恢复审计承包商和两个机构对Medicare整体关节修复患者的审计请求的回应
Audrey N Kobayashi1, Antonia F Chen1, Stephen C Moye1
1Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
The Journal of arthroplasty
|June 6, 2025
概括
实施全关节整形术 (TJA) 的标准化文件,大大减少了康复审计承包商 (RAC) 对医疗保险不当付款的拒绝. 这种方法提高了审计成功率,最大限度地减少了学术和社区医院的财务影响.
科学领域:
- 整形外科手术 整形外科手术
- 医疗保健管理部门的管理.
- 卫生政策 卫生政策
背景情况:
- 美国医疗保险和医疗补助服务中心恢复审计计划 (RAC) 审计医疗保健提供者,以识别和纠正不当支付.
- 收回审计承包商 (RAC) 进行支付后审查,以检测超额支付和不足支付.
- 本研究考察了RAC对全关节整形术 (TJA) 的审计结果,重点关注医疗必要性和文档.
研究的目的:
- 报告两所机构对TJA的RAC审计结果.
- 评估干预措施在改善RAC审计结果方面的有效性.
- 尽量减少RAC审计对TJA程序的财务影响.
主要方法:
- 210个医疗保险TJA病例 (138个学术医疗中心[AMC],72个社区附属医院[CH]) 在一年内被RAC审计.
- 审计涵盖了全关节和全膝关节关节整形术的病例.
- 干预措施包括对手术决策和术前保守护理的标准化文档.
主要成果:
- 最初,6.7%的经过审计的案件 (46个中的6个) 被拒绝支付.
- 在实施标准化文档后,所有后续的审计 (92个案例) 都成功解决了,实现了100%的逆转率.
- 在干预后,在AMC和CH中观察到接受和拒绝率的显著改善.
结论:
- 通过一种协作方法来标准化手术决策和保守护理的文档,将RAC对TJA患者的审计的财务影响降到最低.
- 标准化文档对于成功导航RAC审计至关重要.
- 调查结果强调了在医疗保健补偿方面强有力的文档实践的重要性.
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