CMS calls a temporary halt to the RA program
Audits will resume when new contracts awarded
Executive Summary
The Recovery Auditors (RA) have been prohibited from issuing new post-payment Additional Document Requests since February but can conduct automated reviews until June 1.
• CMS is revamping the RA program and will award new contracts to auditors at an undetermined point in the future.
• Contract changes include fewer records requests for hospitals with low denial rates and postponing RA fees until the second level of appeal.
• Meanwhile, hospitals still have to comply with records requests issued before February.
The Centers for Medicare & Medicaid Services (CMS) has announced a pause in the Recovery Auditor program while it develops new contracts with the auditors, and so the auditors can complete all claims reviews before the current contracts expire.
The Recovery Auditors have been prohibited from requesting post-payment Additional Documentation Requests from providers, beginning Feb. 21, but hospitals that have received requests before that date are still required to respond to them. The RAs can still conduct automated reviews until June 1.
CMS announced the temporary suspension of the program on Feb. 8 "to allow CMS to continue to refine and improve the Recovery Audit Program." The agency has announced a series of changes in the Recovery Audit Program in response to feedback from the healthcare industry. In announcing the changes, CMS said they are designed to increase efficiency and effectiveness and result in "improved accuracy, less provider burden, and more program transparency."
The changes in the RA contracts could make a big difference to hospitals, says Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
One of the program improvements requires the Recovery Auditors to adjust the Additional Document Requests in accordance with denials rates of each hospital. "Under this proposal, hospitals with low denials will get fewer Additional Document Requests and those with more denials will get more requests. This should give hospitals additional incentives to get everything right the first time so they will be subject to fewer audits," Lamkin says.
The new contract provisions revise the Additional Document Requests based on the type of claim (e.g., inpatient, outpatient) and postpones paying auditors their contingency fees until the second level of appeals have been exhausted.
The contracts with the RAs were to end on Feb. 7 of this year, but CMS has extended them through the end of 2015 to give the current contractors time to catch up. CMS has stated that the document requests and audits will resume when the new contracts are awarded but has not announced a date for the new contracts to be effective.
