CMS Details Recovery Auditor Prepayment Review Demo

James Carroll for HealthLeaders Media , December 29, 2011

In addition, James Cope, MD, a medical director with the CERT testing program ran through some of the problems that the report identified with these specific DRGs. For a more detailed summary, an audio recording and transcript of the call will be posted and will be accessible for download beginning on or around December 29. It will be available for 30 days.

How the process will work
The demonstration will begin on January 1, 2012 and will run through the end of 2014. It will be applicable to 11 states, seven of which are HEAT (Healthcare fraud prevention and enforcement action team) states: California, Florida, Illinois, Louisiana, Michigan, New York, and Texas; and four states with high volumes of short inpatient stays: Missouri, North Carolina, Ohio, and Pennsylvania. All facilities that bill to the FI/MAC within those states are subject to the program, according to Cinquegrani.

This demonstration will not replace the ongoing MAC prepayment review program and will serve as a separate entity that aims to help lower the error rate. Providers will not be subject to review for the same topic or issue by two different contractors, according to CMS.

Additional documentation requests will come from the FI/MAC and will contain specific details regarding where providers should submit documentation. Providers will have 30 days to do so; the claim will automatically be denied if documentation isn't received within 45 days. Provided that the recovery auditor receives the documentation, it will then review the claim and communicate a payment determination back to the FI/MAC, according to CMS. Providers will receive the payment determination on the remittance advice within 45 days. Recovery auditors will also send detailed review results letters.

Operational Details
The following is a list of operational details that CMS clarified during the call:

  • Limits on prepayment reviews won't exceed current post-payment ADR (additional documentation request) limits.
  • Providers may appeal the denial and have the same appeal rights as with other denials. Appeal time frames start on the date of the denial as indicated in the remittance advice.
  • Medical records provided on appeal will be remanded to the recovery auditor for review. (This only applies to claims that were denied as a result of nonreceipt of medical records).
  • Claims will be off-limits from future post-payment reviews from MACs and recovery auditors


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