Citing an interest in improving its processes and eliminating unnecessary requirements, CMS is hosting July 13, 2018 “Provider Compliance Focus Group” meeting regarding Medicare fee-for-service compliance topics, including medical review, targeted probe and educate, and Recovery Audit Contractors. CMS states that it wants “to ensure claims are paid appropriately and preserve the Medicare Trust Fund
audits
CMS to Cut Medical Review Audits for Certain Advanced Alternative Payment Model Participants
In order to improve “clinician engagement” and minimize administrative burdens, CMS has announced an 18-month pilot program to reduce medical review audits for participants in selected Advanced Alternative Payment Models (Advanced APMs), beginning January 1, 2017. Under this program, CMS will direct Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and the Supplemental Medical Review…
Senate Finance Committee Approves Medicare Appeals Reform Proposal
On June 3, 2015, the Senate Finance Committee approved by voice vote a bipartisan proposal to reform the Medicare audit and appeals process in an attempt to help ease the backlog of Medicare appeals and promote efficiency and transparency. The draft proposal, the “Audit & Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015,” would, among other things:…
Continue Reading Senate Finance Committee Approves Medicare Appeals Reform Proposal
OIG Responds to Hospital Compliance Review Objections
The OIG has defended its hospital compliance review policies in response to objections raised by the American Hospital Association (AHA). Specifically, a January 15, 2015 OIG letter addresses four main areas of AHA concern about the OIG’s application of Medicare rules and policies: (1) the need for a physician order, (2) the treatment of canceled…
CMS Guidance on Provider Timeframes for Responding to Additional Documentation Requests
CMS has updated the Medicare Program Integrity Manual to clarify that providers and suppliers have 45 days to produce documents in response to a pre-payment review Additional Documentation Request (ADR) issued by a Medicare Administrative Contractor (MAC) or Zone Program Integrity Contractors (ZPIC). MAC and ZPIC reviewers are instructed not to grant extensions to providers…
GAO Calls for Improvements to Medicare Contractor Postpayment Review Process
The Government Accountability Office (GAO) has issued a report entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews." In the report, the GAO assesses CMS policies and procedures to prevent certain Medicare contractors (Medicare Administrative Contractors, Zone Program Integrity Contractors, Recovery Auditors, and the Comprehensive Error…
CMS Adds MAC/RAC “Provider Relations Coordinator” for Auditor Process Issues
In an effort to “increase program transparency and offer more efficient resolutions to providers” subject to the medical review process, CMS has created the new position of “Provider Relations Coordinator." The Provider Relations Coordinator is intended to improve communication between providers and CMS on medical review process issues. For instance, providers can contact…
CMS Announces RAC Audit “Pause,” Upcoming RAC Program Reforms
CMS has announced that it is “pausing” Recovery Audit Contractor (RAC) audits in preparation for the procurement of new RAC contracts and to “allow CMS to continue to refine and improve the Medicare Recovery Audit Program.” The following is the timeline for winding down current RAC activities:
- February 21 is the last day a RAC
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CMS Continues to Modify Implementation of 2-Midnight Inpatient Admissions Policy
On February 24, 2014, CMS posted additional guidance on its controversial “2 Midnight Rule” Medicare inpatient hospital admission and medical review criteria. Among other things, CMS is requesting Medicare Administrative Contractors (MACs) to re-review claims denials made during the “probe and educate” phase of implementation to make sure that MACs are applying CMS…
CMS Guidance on Medicare Inpatient Hospital Admissions Two-Midnight Policy
CMS continues to release subregulatory guidance on the inpatient hospital admission/medical review criteria that were adopted in the final FY 2014 Medicare inpatient prospective payment system/long-term care hospital final rule. In short, under this new policy, if the ordering practitioner expects a beneficiary’s surgical procedure, diagnostic test, or other treatment to require a stay in…
CMS Resources on Provider EHR Audits
CMS is reminding eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) attesting to receive an incentive payment for either the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program that they may be subject to a pre-payment or post-payment audit. CMS has provided a fact sheet on supporting documentation for providers selected…