Recovery
Audit Program
Mission - The Recovery
Audit Program’s mission is to identify and correct Medicare improper payments
through the efficient detection and collection of overpayments made on claims
of health care services provided to Medicare beneficiaries, and the
identification of underpayments to providers so that the CMS can implement
actions that will prevent future improper payments in all 50 states.
Background - The national
Recovery Audit program is the product of a successful demonstration program
that utilized Recovery Auditors to identify Medicare overpayments and
underpayments to health care providers and suppliers in randomly selected
states. The demonstration ran between 2005 and 2008 and resulted in over $900
million in overpayments being returned to the Medicare Trust Fund and nearly
$38 million in underpayments returned to health care providers. As a result,
Congress required the Secretary of the Department of Health and Human Services
to institute (under Section 302 of the Tax Relief and Health Care Act of 2006)
a permanent and national Recovery Audit program to recoup overpayments associated
with services for which payment is made under part A or B of title XVIII of the
Social Security Act.
Each
Recovery Auditor is responsible for identifying overpayments and underpayments
in approximately ¼ of the country. The Recovery Audit Program jurisdictions
match the DME MAC jurisdictions.
The
Recovery Auditor in each region is as follows:
Region A: Performant Recovery
Region B: CGI Federal, Inc.
Region C: Connolly, Inc.
Region D: Health Data Insights, Inc.
Q
& A
Will The Recovery Auditors Affect Me?
Yes, if you bill fee-for-service programs,
your claims will be subject to review by the Recovery Auditors.
What Does A Recovery Auditor Do?
·
The
Recovery Audit Review Process:
·
Recovery
Auditors review claims on a post-payment basis
·
Recovery
Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs
and the CMS Manuals
·
Three
types of review:
o Automated (no
medical record needed)
o Semi-Automated
(claims review using data and potential human review of a medical record or
other documentation)
o Complex (medical
record required)
·
Recovery
Audits look back three years from the date the claim was paid
·
Recovery
Auditors are required to employ a staff consisting of nurses, therapists,
certified coders and a physician CMD
Ensure Accuracy
·
Each
Recovery Audit team employs:
o Certified coders
o Nurses
o Therapists
o A physician CMD
·
The
CMS’ New Issue Review Board provides greater
oversight
·
Recovery
Audit Validation Contractor provides annual
accuracy scores for each Recovery Audit
organization
·
If
a Recovery Auditor loses at any level of appeal, the
·
Recovery
Auditor must return its contingency fee
Have
you taken the necessary steps to avoid an Audit?
Does
your documentation support the level of service?
Does
your coding qualify the various Quality Measures ?
Quality Measures
are defined as:
·
Meaningful Use
·
Core Measures
·
HEDIS
·
PQRS
·
National Quality
Measures
FOR MORE
INFORMATION PLEASE CONTACT:
HPP Management
Group, Corp.
Developers of
the AccuChecker Product Line
Phone: (305)
227-2383
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