Changes to the Recovery Audit Program for 2016
The Centers for Medicare & Medicaid Services (CMS) has made a number of changes to the Recovery Audit Program for 2016.
One of those changes is the length of time a provider has to submit a Discussion Request to a recovery audit contractor (RAC) following an automated review. CMS is also establishing Additional Documentation Request (ADR) limits for facilities.
Effective January 1, 2016, The CMS revised the method used to calculate ADR limits for the Medicare fee-for-service Recovery Audit Program for facilities. Institutional providers with low denial rates will have lower ADR limits while providers with high denial rates will have higher Additional Documentation Request (ADR) limits. Additional Documentation Request (ADR) limits will be adjusted as a facility?s denial rate increases or decreases.
It must be noted that the change does not apply to physician and non-physician practitioners and suppliers.
CMS is actively preparing for the next round of recovery auditor contracts. Recovery Audit Contractors (RAC) must complete all discussion periods by August 28, 2016 and October 1, 2016, is the last day a Recovery Audit Contractor may send claim adjustment files to Medicare administrative contractors (MACs).
Providers may still receive some correspondence from their current Recovery Audit Contractor (RAC) during the transition. ?However,? CMS says, ?at no time will providers have to respond to additional Documentation Request(s) more frequently than every 45 days, or from two different Recovery Auditors.?
There are three types of reviews a Recovery Audit Contractor may perform. Each has different provider response requirements and timelines.
- Automated: No medical records are requested or reviewed. Discovery is done through data-mining. All automated reviews initiated after January 1, 2016, will be posted on the RAC?s Provider Portal when they are identified. This will serve as the start of the provider?s 30-day window for submitting a discussion request.
- Semi-automated: These reviews are similar to automated reviews except they are used where a clear CMS policy doesn?t exist, but the items and services as billed are clinically unlikely or not consistent with evidence-based medical literature. The recovery auditor sends an Informational Letter to the provider detailing its findings. The provider has the option to submit additional documentation and/or an explanation within 45 days of receipt of the Informational Letter. If the Recovery Audit Contractor doesn?t receive any additional documentation, the adjustment is submitted to the Medicare Administrative Contractors.
- Complex: Claims are selected for review, and the RAC sends an Additional Documentation Request (ADR) to the provider. Effective January 1, 2016, the RAC has 30 days to conduct the review from the date the documentation is received. If the documentation is not received within 45 days, the RAC is supposed to make one good faith effort to follow up with the provider. If no documentation is subsequently received, the full amount of the claim is sent to the MAC for adjustment.