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· Recovery Audit Contractors revised to Recovery Auditors.


· Additions and Clarifications that the Recovery Audit Program includes all contracts, all types of claims with the focus being on lower error rates and identifying improper payments with the greatest impact on the Trust Fund to prevent misunderstandings. Medicaid RAC documents have referred to Medicare Recovery Auditor focus limitations as acute care facilities.


· Addition of a new type of review – “semi-automated review” a new two-part review process that can include both automated and complex reviews. This review type does not pay providers for medical record submissions.


· Clarification of DRG Validation versus Clinical Validation by adding definitions.


· Addition of language for “Allowance for a Discussion Period” to clarify this process – e.g., an escalation process for the discussion period, where a physician (or a physician employed by the provider) may request to speak to the Recovery Auditor physician and new directives that once an appeal is filed with the MAC, the discussion period must be discontinued. This minimizes duplications of effort by the Recovery Auditor and MAC.


· Change to the Recovery Auditor website’s listing of new issues whereas the new issue list must be sortable by a minimum provider type by June 1, 2011.


· Addition that CMS reserves the right to share new issues with all CMS review entities. (Collaboration)


· Clarification of Recovery Auditors and MACs roles.


· Addition of Recovery Auditor activities when CMS refers potential improper payment notices (Technical Direction Letter) to them.


· Further clarification on the Adjustment Process as it relates to associated findings.


About the Author


Vickie Axsom-Brown is president of Audits & Recovery Solutions. She is a 20-year managed care veteran with diverse experience in administering private, state and federal healthcare services. Her management experience includes time spent as the vice president of Region D RAC services (as the principal lead for CMS, claims processing contractors and HDI services) and as CEO/COO of multidisciplinary, multi-site adult and pediatric medical/surgical providers, including oncology/radiology services, laboratory services, ambulatory surgery centers, upright MRIs, PETs, and others.


Contact the Author




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Statement of Work for the Recovery Audit Program


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