July 10, 2015 - Effective June 4, 2015, CMS has withdrawn the Requests for Quotes for the next round of Recovery Auditor contracts. CMS plans to update the Statement of Work and release new Requests for Proposals shortly. In the meantime, the current Recovery Auditors will continue active recovery auditing through at least December 31, 2015.
July 10, 2015 – In mid-January 2015, CMS approved the Recovery Auditors to begin reviewing Outpatient Therapy Threshold claims (those over the $3700 threshold) that were paid March 1, 2014 through December 31, 2014. In an effort to minimize provider burden, CMS set restrictions on the number of Additional Documentation Requests (ADRs) that could be sent related to these claims, as shown below.
1st ADR: can only request documentation for 1 claim
2nd ADR: can request up to 10% of total eligible1 claims
3rd ADR: up to 25% of remaining eligible claims
4th ADR: up to 50% of remaining eligible claims
5th ADR: up to 100% of remaining eligible claims
(1 Total number of claims over the $3700 Threshold that were paid March 1, 2014 through December 31, 2014)
The information above is not related to the Medicare Access and CHIP Reauthorization Act of 2015.
March 26, 2015 – CMS will be implementing Change Request (CR) 8844, which creates a new Informational Unsolicited Response (IUR) within the Common Working File (CWF) to identify DME claims that overlap a Part A inpatient stay. This CR will be effective for claims with dates of service on or after April 1, 2015. Recovery Auditor reviews related to DME items, that were provided while the beneficiary was in an inpatient stay, will be limited to DME claims paid on or after April 1, 2015.
January 14, 2015 – Due to a post-award protest filed at the Government Accountability Office (GAO), CMS has delayed the commencement of work under the national DMEPOS/HH&H, Region 5, Recovery Audit contract. Questions regarding the protest may be directed to the GAO. CMS will post updates on this website, as appropriate.
December 30, 2014 – CMS has awarded the Region 5 Recovery Audit contract to Connolly, LLC. The purpose of this contract will be to support the Centers for Medicare & Medicaid Services (CMS) in completing this mission through the identification and correction of improper payments for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and home health/hospice (HH/H) claims submitted under Title XVIII of the Social Security Act (the Act). The Recovery Auditor will review all applicable claims types through the appropriate review methods and work with CMS and the DME and HH/H MACs to adjust claims to recoup overpayments and pay underpayments. This award marks the beginning of the new Recovery Audit contracts and is the start date of the implementation of many improvements to reduce provider burden and increase transparency in the program. A detailed list of these improvements can be found at Recovery Audit Program Improvements.
November 4, 2014 – Procurement Update: The new contracts for Recovery Auditor Regions 1, 2, and 4 remain under a pre-award protest, which is expected to continue into late summer of 2015. However, the procurement process continues for Region 3 (Part A / Part B claim reviews), which includes Florida, Tennessee, Alabama, Georgia, West Virginia, Virginia, North Carolina and South Carolina; and, for Region 5, which will be the national contract for DMEPOS and Home Health & Hospice claim reviews. The CMS remains hopeful that these two new contracts will be awarded before the end of this year.
August 28, 2014 – A contract modification, allowing the current Recovery Auditor to restart some reviews has been completed for Region C. Most reviews will be done on an automated basis, but a limited number will be complex reviews of topics selected by CMS.
August 27, 2014 – A contract modification, allowing the current Recovery Auditors to restart some reviews has been completed for Regions A, B, and D. Most reviews will be done on an automated basis, but a limited number will be complex reviews of topics selected by CMS.
August 4, 2014 – Due to the continued delay in awarding new Recovery Auditor contracts, the CMS is initiating contract modifications to the current Recovery Auditor contracts to allow the Recovery Auditors to restart some reviews. Most reviews will be done on an automated basis, but a limited number will be complex reviews of topics selected by CMS.
Work continues on the procurement process for the four Part A / Part B Regions and the national DMEPOS/HH&H Region. The CMS remains hopeful that the new round of Recovery Auditor contracts will be awarded this year.
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.
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