The Centers for Medicare & Medicaid Services (CMS) has announced a number of changes to the Recovery Audit program that will become effective when each new contract is issued. The process to rebid the contracts has been halted because of a lawsuit by a contractor, according to Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
The announcement issued by CMS states that the changes were made in response to concerns about the program raised by the healthcare industry and that the changes are expected to result in “a more effective and efficient program, by enhanced oversight, reduced provider burden, and more program transparency.”
Here are some of the changes mentioned in the announcement:
• Providers that comply with Medicare rules will have fewer Recovery Audit reviews. Additional document requests will be lower for providers with lower denial rates and will be adjusted as a provider’s denial rate decreases. Currently, the additional document request limits are the same for providers of a similar size.
• If a hospital submits a claim for an inpatient stay within three months of the date of service, the recovery auditors will have only six months from the date of service to review the claim for patient status. This is a change from a three-year look-back period.
• Under the new rules, recovery auditors will have 30 days to complete complex reviews and notify providers of their findings, instead of the current 60 days.
• Recovery auditors will not receive a contingency fee until after the second level of appeal is exhausted. The current rules call for the RAs to be paid immediately on denial and recoupment of claims.
• The recovery auditors will be required to have less than 10% of their denials overturned at the first level of appeal, not including claims that were denied due to no or insufficient documentation or claims that were corrected during the appeals process. RAs that have a higher overturn rate will be placed on a corrective action plan that may include decreasing the additional document request limits or stopping certain reviews until the problem is corrected. The current program has no penalties for high appeal overturn rates.
• Recovery auditors will have to maintain an accuracy rate of at least 95% on automated reviews or face a progressive reduction in limits on additional document requests.
• CMS has established a provider relations coordinator that providers can contact when issues arise that aren’t resolved by discussions with the recovery auditor.
• CMS is considering developing a provider satisfaction survey to obtain feedback on the performance of recovery auditors.
To read the CMS announcement on the new rules, visit http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-Program-Improvements.pdf.