CMS Announces Updates to the Recovery Audit Program.

On December 30, 2014, the Centers for Medicare & Medicaid Services (CMS) announced new Recovery Audit contracts and updates to the Recovery Audit Program.  The changes will reduce provider burden and increase transparency in the program.

Key updates to the Recovery Audit Program include:

• The look-back period for patient status reviews is limited to 6 months in cases where the hospital submits the claim within 3 months of the date of service;
• Additional Documentation Requests (ADR) limits will be based on providers’ compliance with Medicare rules, corresponding with a provider’s denial rates;
• ADR limits will be diversified across all claim types of a facility;
• Recovery Auditors will not receive a contingency fee until after the second level of appeal is exhausted;
• Recovery Auditors must wait 30 days prior to sending the claim to the Medicare Administrative Contractor for adjustment to allow for a discussion request; and
• Recovery Auditors must maintain an overturn rate of less than 10 percent at the first level of appeal, or will be subject to a corrective action plan.

A list of the improvements to the Recovery Audit Program is available at:

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-Program-Improvements.pdf.

Centers for Medicare & Medicaid Services.  “Recent Updates.”  14 Jan. 2015

<http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html>.

Centers for Medicare & Medicaid Services.  “Recovery Audit Program Improvements.”  30 Dec. 2015.