CMS Lists RAC Program Improvements

The Centers for Medicare and Medicaid Services (CMS) recently published a list of Recovery Audit Contractor (RAC) program improvements that have been completed as of a year ago. Read the list.

The document highlights the following RAC program improvements that have been made as of October 2016, with a note on their effective date:

  • CMS developed a Provider Satisfaction Survey which gives “providers an outlet to give feedback to CMS on the Recovery Auditors’ performance.” (Completed April 2016)
  • Recovery Auditors now have 30 days to complete complex reviews and notify providers of their findings, rather than 60 days. This provides more immediate feedback to the provider on the outcome of their reviews. Recovery Auditors will continue not to receive a contingency fee for those complex reviews that are not completed within the required timeframe. (Effective December 31, 2015)
  • Recovery Auditors must wait 30 days to allow for a discussion request before sending the claim to the MAC for adjustment. Providers will not have to choose between initiating a discussion and an appeal and can be assured that modifications to the improper payment determination will be made prior to the claim being sent for adjustment. (Effective December 31, 2015).
  • Recovery Auditors must confirm receipt of a provider’s discussion request or other written correspondence within three business days. (Effective December 31, 2015).  In October 2016, CMS changed the receipt confirmation deadline to one business day under the new  RAC contracts
  • CMS worked with Recovery Auditors to enhance their provider portals, including more uniformity and consistency in the claim status section, as well as display reason statement identifiers where available. (Effective December 31, 2015)
  • CMS now requires the Recovery Auditors to broaden their review topics to include all claim/provider types, and will be required to review certain topics based on a referral, such as an OIG report. (Effective December 31, 2015)
  • Recovery Auditors will not receive a contingency fee until after the second level of appeal is exhausted. Previously, Recovery Auditors were paid immediately upon denial and recoupment of the claim. This delay in payment helps assure providers that the decision made by the Recovery Auditor was correct based on Medicare’s statutes, coverage determinations, regulations, and manuals. (Effective October 31, 2016)

The North Carolina Medical Society (NCMS) has long advocated for reform of the RAC program through our partnerships with other state medical societies and by direct lobbying by our members at the federal level.

 
 

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