CMS Announces "Pause" in RAC Audits

Carl Pucci and Nancy Leveille in Finance & Reimbursement

AHCA notified NYSHFA of the following:

At the Administrative Law Judge (ALJ) Forum last week, CMS heard that a significant increase in the number of audits in the Recovery Audit (RA) program over the last several years is a major factor for the 2+ year backup at the ALJ level.  On Tuesday, 2/18/14, CMS announced on its website that it is “pausing” RA audits in preparation for the procurement of new RA contracts and to “allow CMS to continue to refine and improve the Medicare RA Program.”  To obtain a complete copy of the announcement go to http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html.

Specifically, CMS states in the announcement that it is in the procurement process for the next round of RA Program contracts.  According to CMS, it is important that the agency transition down the current contracts so that the RAs can complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the RA Program.  Several years ago, CMS stated that it made substantial changes to improve the RA program, and it will continue to review and refine the process as necessary.  Providers should note the important dates below:

  • February 21 is the last day an RA may send a post-payment Additional Documentation Request (ADR)
  • February 28 is the last day a MAC may send prepayment ADRs for the RA Prepayment Review Demonstration
  • June 1 is the last day a RA may send improper payment files to the MACs for adjustment

Any questions from providers should be directed to RAC@cms.hhs.gov.

  NYSHFA CONTACTS: Carl J. Pucci
Director, Finance & Reimbursement
518-462-4800 x36
  Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20