Home Health & Hospice Week

The Centers for Medicare & Medicaid Services is reining in its Recovery Audit Contractors somewhat, but it may not stay that way. Starting in January, CMS is establishing Additional Development Request limits for RACs based on a provider’s compliance with Medicare rules, CMS notes on its RAC web page. “Providers with low denial rates will have lower ADR limits while providers with high denial rates will have higher ADR limits,” CMS says. “The ADR limits will be adjusted as a provider’s denial rate decreases, resulting in the provider that complies with Medicare rules having less Recovery Auditor reviews.” For facility claims, RACs will be allowed to audit only 0.5 percent of all claims paid during a 45- day period, compared to the current 2 percent, according to press reports. And CMS plans to reduce the time that RACs are given to complete complex claim reviews from 60 days to 30 days. CMS isn’t changing ADR levels for physicians or DME suppliers, CMS notes.

According to the Wall Street Journal, RACs recouped $2.4 billion last year, down more than a third from the $3.7 billion recovered in 2013. Not everyone is happy about the changes.

“CMS should be stepping up a vibrant oversight presence” for Medicare, Sen. Orrin Hatch (RUtah) said in a Nov. 12 letter to Acting CMS Administrator Andy Slavitt. Hatch questioned pulling back on RAC review when recoupments are down significantly.

“Despite all of the critiques of the RAC Program and the Medicare appeals process, the Department of Health and Human Services is fully invested in using them as tools to address inaccurate and erroneous payments in the Medicare program,” notes law firm Mintz Levin in analysis of the changes. “These recent changes and announcements show the agency’s attempts to address provider concerns.”

See the list of RAC program changes at www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Recovery-Audit-Program/Downloads/Recovery-Audit-Program-Enhancements11-6-15-Update-.pdf.