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Recent Updates

June 2,  2014 – CMS is pleased to announce the establishment of a Provider Relations Coordinator to help increase program transparency and offer more efficient resolutions to providers affected by the medical review process.   

CMS established the Provider Relations Coordinator to improve communication between providers and CMS.  Although providers should continue to take questions about specific claims directly to the Recovery Auditor or Medicare Administrative Contractor (MAC) who conducted the review, providers can raise larger process issues to Coordinator.  For example, if a provider believes that a Recovery Auditor is failing to comply with the documentation request limits or has a pattern of not issuing review results letters in a timely manner, CMS would encourage the provider to contact the Provider Relations Coordinator.  

Providers can also send suggestions about how to improve the Recovery Auditor or MAC medical review process to the CMS Provider Relations Coordinator.  

The CMS Provider Relations Coordinator is: Latesha Walker.

Providers may contact Latesha by sending an email to:
• RAC@cms.hhs.gov  (for Recovery Auditor review process concerns/suggestions)
• MedicareMedicalReview@cms.hhs.gov  (for MAC review process concerns/suggestions)

May 7, 2014 – The following information is intended to notify providers of current Recovery Auditors’ activities after June 1, 2014.

As noted in previous updates, the last day that Recovery Auditors may send claim adjustment files to the Medicare Administrative Contractors (MAC) is June 1, 2014.  As of June 2, 2014, only claim closure files may be sent to the MACs, by the Recovery Auditor.   

Because no additional reviews will occur under the current contracts, current Recovery Auditors will not be required to update the “New Issue” (“Approved Issue”) portion of their websites, as of June 2, 2014. However, Recovery Auditors shall continue to update the “Claims Status” portion of their provider portal, in a timely manner, until further notice.

Recovery Auditors shall complete all Discussion Periods that are underway as of June 1, 2014. Recovery Auditors shall continue to accept new Discussion Period requests until June 30, 2014. All Discussion Periods initiated during June shall be completed. Recovery Auditors shall not accept new Discussion Period requests on or after July 1, 2014.

Recovery Auditors shall continue to maintain their customer service areas (telephone lines and appropriately training staff) and process for escalating concerns, until further notice.

Recovery Auditors shall continue to support the appeal process.

Note: Medicare Administrative Contractor (MAC) processes will continue. Therefore, claims sent for adjustment, by a Recovery Auditor, on or before June 1, 2014 may complete the adjustment process on, or after, June 2, 2014. The Medicare Appeals process will also continue. Therefore, recoupments can occur, if a provider does not file a timely appeal (to the 1st or 2nd level of appeal), or receives an “unfavorable” decision at the 2nd level (QIC) of the appeals process.

March 7, 2014 – Now that the dates for sending Addition Documentation Request (ADR) letters have passed, CMS would like to remind providers that the Recovery Auditors can continue to conduct automated reviews (reviews that do not require soliciting medical record documentation from providers) through June 1, 2014. Recovery Auditors will also continue to complete the reviews for the ADRs they’ve already sent as of 2/28/2014. Providers have 45 days to respond to an ADR and Recovery Auditors have up to 60 days to make a determination on the claim.  In general, CMS will not conduct post-payment patient status reviews for claims with dates of admission October 1, 2013 through October 1, 2014.

February 18, 2014 – CMS is in the procurement process for the next round of Recovery Audit Program contracts.  It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program.   Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program.  CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers.  CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders.  Providers should note the important dates below:
• February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)
• February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration
• June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment
CMS will continue to update this Website with more information on the procurement and awards as information is available. Providers should contact RAC@cms.hhs.gov for additional questions.

January 8, 2014 – As CMS continues the procurement process for the new Recovery Audit Program contracts, the current Recovery Audit Program contracts will be extended several months. In particular, the active recovery auditing period would be extended through the awards and implementation phases of the new contracts. Active recovery auditing includes sending additional documentation requests/semi-automated notification letters and initiating automated reviews.

Requests for Quotes (RFQs) will be issued through the General Services Administration. Maps of the new jurisdictions can be found on the Future Changes section of the Recovery Audit Program website.
Providers may still receive some correspondence related to the outgoing Recovery Auditor contracts while CMS transitions to the new contracts. However, at no time will providers have to respond to ADRs more frequently than every 45 days, or from two different Recovery Auditors.
Providers should contact RAC@cms.hhs.gov for questions concerning the transition. CMS will continue to update this Website with more information on the procurement and awards as information is available.

10/22/12 - Change in Recovery Auditor for Some Providers

If a provider is located in any state other than Missouri, Kansas, Iowa or Nebraska (i.e. Jurisdiction 5 for Wisconsin Physician Services (WPS), and WPS is their Medicare Administrative Contractor (MAC), there has been a change in their Recovery Auditor.  As of 10/22/12 the Recovery Auditor for these providers is HealthData Insights.

This change occurred because the Centers for Medicare & Medicaid Services (CMS) completed a contracting transition involving the MAC. This transition did not impact the provider’s MAC but the transition required the change in the Recovery Auditor.  

All impacted providers will be notified by HealthData Insights via postal mail.

All open additional documentation requests and any requests where a demand letter has not been generated were canceled and closed. Claims in process and claims data from the other Recovery Auditors will not be shared with HealthData Insights

Note:  This does not impact providers in Jurisdiction 8 where WPS is also the Medicare Administrative Contractor.  The change in Recovery Auditor is only specific to those providers who originally had WPS pay their claims as the national fiscal intermediary.

March 26, 2012- Beginning April 1, 2012, CMS will begin instituting a reimbursement cap of $25 per medical record.  Any medical record submitted to a Recovery Auditor after April 1, 2012 will receive a maximum of $25 per medical record.  This includes both the $0.12 per-page cost for photocopying, as well as first class postage.    

Do you have questions or comments about the Recovery Audit Program? Please e-mail us at: RAC@cms.hhs.gov. Please Do Not send Personal Health Information to this e-mail address. Thank you.