Tuesday, November 24, 2015

CMS Announces the Continuation of Recovery Audit Improvements

Dan Ciolek and Dianne De La Mare


On November 6, the Centers for Medicare and Medicaid Services (CMS) provided several updates regarding their efforts to improve the Medicare Recovery Audit program.

First, CMS announced that they have issued new Requests for Proposals (RFPs) for the next round of Recovery Auditor contracts at the Federal Business Opportunity website . The new RFPs were necessary as a Federal Court found the earlier versions were improper. CMS anticipates the new Recovery Audit contracts to be awarded in 2016.

Second, CMS posted a revised Additional Documentation Request Limits document that describes a new process for Recovery Audits beginning January 1, 2016. These limits will apply to all providers except Physicians and Suppliers.

Third, CMS posted an updated Recovery Audit Program Enhancements document showing the status of the enhancements currently in place, in progress, those that require modifications to existing contracts, and those incorporated into the new Recovery Audit Contract RFPs just released.

Overall many of the Recovery Audit Improvements were advocated for by AHCA on numerous occasions and do several positive things for all providers, including skilled nursing facilities (SNF) such as:

Protect providers from overzealous Recovery Audit additional development requests (ADRs)
o Annually limited to no more than 0.5% of provider claims per year

o Limited to sending ADR letters to no more frequently than every 45 days to allow provider to respond to earlier requests

o Providers with low denial rates on Recovery Audit reviews will have their review rate dropped even lower than the starting 0.5% rate (those with high denial rates may see an increase)

Adds Recovery Auditor accountability to reduce risk of overzealous inappropriate denials
o Recovery Auditor s are penalized with overturns on appeal rate of >10%

o Recovery Auditor s are penalized for accuracy rates of <95%

o Recovery Auditor s are now subject to provider satisfaction surveys

o Recovery Auditor s are now subject to public reporting (similar to 5 star) on how they comply with these metrics

Other current and future enhancements are related to improved education, technology use, clinical expertise, timeliness, etc.

Members with questions may contact Dan Ciolek or Dianne De La Mare.

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