• Savvy Coder

    Recovery Audits, Part 1: RA Program 101

    Written By: Sue Vicchrilli, COT, OCS, Academy Coding Executive

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    Over the past 14 months, the four CMS Recovery Audit entities (RAs)—which were formerly known as Recovery Audit Contractors (RACs)—have had a huge impact, with far more ophthalmologists being subject to RA audits than ever before. This series of articles is designed to educate ophthalmic practices about the nuances of this type of audit.

    What is the RA program? CMS contracts with four companies to act as RAs, with the goal of finding improper payments (either overpayments or underpayments) to Medicare Part B physicians. RAs can review claims on a postpayment basis.

    Do RAs replace other audit entities? No. Several other audit entities continue to review claims:

    • Medicare Administrative Contractor (MAC)
    • Comprehensive Error Rate Testing (CERT) Contractor
    • Zone Program Integrity Contractor (ZPIC)
    • Office of Inspector General (OIG)
    • Quality Improvement Organization (QIO)

    RAs will not review claims previously examined by another audit entity.

    How do RAs determine what to audit? An RA develops a proposal about the areas it wants to review based on its knowledge of Medicare’s rules and regulations, such as the Local Coverage Determinations (LCDs). The RA then forwards the proposal to the MAC. The MAC reviews the proposal and provides recommendations to CMS, which either approves or disapproves the new target area.

    Do RAs ask for your medical records? If you are subject to an automated (or data driven) review, you won’t be asked for medical records. In complex reviews, however, the RA will want to see the medical records that support your claims. When the RA asks physicians for this extra documentation, it must ask for at least 20 claims over 45 days.

    Who Is the RA for Your State?

    Each RA is responsible for one region.

    Performant is the RA for Region A, which covers 11 states in the Northeast and Middle Atlantic—Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont—plus the District of Columbia (www.Performantrac.com).

    CGI is the RA for Region B, which covers seven states, mostly in the Midwest—Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin (http://racb.cgi.com).

    Connolly is the RA for Region C, which covers 15 states in the South and Southwest—Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia—plus two dependent territories—Puerto Rico and U.S. Virgin Islands (www.connollyhealthcare.com/RAC).

    Health Data Insights is the RA for Region D, which covers 17 states, mostly in the West—Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming—plus three dependent territories—American Samoa, Guam, and Northern Mariana Islands (https://racinfo.healthdatainsights.com).

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    NEXT MONTH: Examples of real RA audits.

    More at the Meeting

    Audits: It’s Not a Matter of If, But When. Sue Vicchrilli, COT, OCS, Stephen Kamenetzky, MD, and Academy director of health policy Cherie McNett will discuss the range of audits that you might face, and the steps to take when you receive a request for documentation. When: Sunday, Oct. 19, 2:00-4:15 p.m. Where: Room S501a. Access: Academy Plus course pass.