CMS Announces Pause in RAC Audits Updated by AHCA

Carl Pucci and Nancy Leveille in Finance & Reimbursement

On Thursday, February 20th, NYSHFA's member mailing noted that CMS Announcement a "Pause" in RAC audits (see attached member mailing.)  However, due to the vague CMS announcement, and the fact that the Part B therapy pre- and post-pay Manual Medical Review (MMR) process is a separate activity performed by RACs, and not part of the formal RAC program, providers have been receiving conflicting information from their Medicare administrative contractors (MACs) and RACs.  AHCA has contacted CMS, and received the following written email clarification on February 21st:        

  • February 21, 2014 is the last day for Recovery Auditors to send ADR letters (complex reviews and semi-automated reviews). This date also applies to post-payment reviews of Outpatient Therapy claims over the $3700 Threshold.
  • February 28, 2014 is the last day for MACs to send ADR letters for the Recovery Auditor Prepayment Demonstration (complex reviews). This date also applies to prepayment reviews of Outpatient Therapy claims over the $3700 Threshold.
  • If a provider has already received an ADR letter, or will receive one of the last ones (sent by the end of this month), the provider must comply with the request and submit the records, or a denial will be made on the involved claim(s).
  • Any records that were previously submitted to the Recovery Auditor will continue to be reviewed, and the provider will receive a review results letter, as usual.

This is an extremely positive development for SNF providers that receive the brunt of MMR ADRs due to the needs of the patient population we serve.  This ‘pause’ will permit providers to focus more on furnishing care for their current patients, while working to clear the backlog of current MMR ADRs and related appeals.  Please note that this ‘pause’ does not preclude providers from responding as required to any ADRs they receive, or have already received.  CMS has not yet reported an end-date for this ‘pause’.

CMS also indicated that they intend to provide more detailed clarification next week.  AHCA is developing and compiling questions to present to CMS next Monday to better assure that their clarification addresses any questions we have regarding process or implications.  We will also be updating members to new developments through the various AHCA member outreach vehicles including the new AHCA therapy services MMR page at: http://www.ahcancal.org/facility_operations/therapyservices/Pages/Manual-Medical-Review.aspx

If you have any questions you would like included in our list for CMS, please send them to dciolek@ahca.org as soon as possible.

  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