Home Health & Hospice Week

Some successful appeals don't count against Performant.

Look to Performant's contract with Medicare to find out how its payment methodology influences the Recovery Audit Contractor's motivations to deny your claims.

In the "Statement of Work for the Medicare Fee-for-Service Durable Medical Equipment and Home Health/Hospice Recovery Audit Program - Region 5," the Centers for Medicare & Medicaid Services spells out these payment details:

• "CMS expects that each Recovery Auditor shall have an appeal overturn rate of less than 10% at the first level of appeals for each fiscal year... The data warehouse will calculate a rolling tally of all unfavourable appeal determinations (due to misapplication of CMS policy). For each percentage point below 10%, Recovery Auditors shall earn a .1% contingency fee increase. For example, a Recovery Auditor with a base rate of 15% and a 9% appeal overturn rate would receive a .1% contingency fee increase, or 15.1%."
• The appeal overturn rate "only includes decisions where a Recovery Auditor made an incorrect claim determination. Instances where a provider presents new information or corrects the claim will not be included." Also, "appeal overturn rates will be calculated by CMS for specific review issues. The adjusted contingency fee will apply to all claims with collections or paid underpayments under the identified review.

Appeal overturn rates and contingency fees will be recalculated every three months by CMS."

• Additionally, "failure to maintain an overturn rate of less than 10% at the first level of appeal will result in CMS taking necessary action, including, but not limited to, progressive reduction in ADR limits, requiring the Recovery Auditor to prepare a Corrective Action Plan, CMS' decision to not exercise the next option period of the contract, modification/termination of the contract, etc."

Note: The Region 5 SOW is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-AuditProgram/Downloads/New_RAC-SOWRegion-5-clean.pdf.