Recovery Auditor Prepayment Review Demos Imminent

James Carroll, for HealthLeaders Media , August 10, 2012

Further clarification
CMS also clarified a number of details during the aforementioned open door forum:


  • 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.

For those states that are involved in the demonstration program, or for those providers who may want to get a head start on preparing for a possible full-time prepayment review process, it may be a prudent move to start ensuring the completeness of medical records before they go out of the door, says Sharon Easterling, MHA, RHIA, CCS, CDIP, CEO of Recovery Analytics in Charlotte, N.C.
Make sure that the records do not have any signature issues, make sure that they have been pre-reviewed, and make sure that they contain all the necessary documentation; these are the most important aspects of the record, explaines Easterling.

She goes on to mention that if providers receive prepayment review denials, they should look into appealing that determination. "Appeal, appeal, appeal; when you read that [the recent CMS update that came out on appeals], you tend to think that providers aren't appealing enough," she says. "Continue to appeal and work on documentation efforts."

See more information on the prepayment review demonstration program.

James Carroll is associate editor for the HCPro Revenue Cycle Institute.
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