Health Law Daily Wrap Up, HEALTH CARE COMPLIANCE NEWS—CMS changes limits on Recovery Audit Contractors’ claims requests, (Apr 10, 2013)

By Michelle L. Oxman, JD, LLM

CMS has announced changes to the limit on the number of additional document requests (ADRs) that Recovery Audit Contractors (RACs) may make to providers. Effective April 15, 2013, no more than 75 percent of the documents requested may be from any one type of claim. The claim types include inpatient prospective payment system (IPPS), outpatient PPS (OPPS), skilled nursing facility (SNF), inpatient psychiatric facility (IPF), inpatient rehabilitation facility (IRF), ambulatory surgical center (ASC), and physician claims. Interim and final bills are treated as one claim.

The policy limits the number of claims that may be requested both in one year and in each 45-day period. RACs may demand 2 percent of the prior year’s claims in one year; no more than 1/8 of that number may be requested in each 45-day period, up to a maximum of 400. Providers with more than $100 million in MS-DRG payments for the previous year may be required to produce 600 claims per 45-day period. At least 20 claims may be included in each request.

CMS may grant exceptions in individual cases, either on its own initiative or on request of the RAC. Either CMS or the RAC will notify the provider if an exception has been authorized.

According to the American Hospital Association, the 2,335 hospitals that participate in its quarterly RACTrac survey reported dramatic increases in RAC activity in the 4th quarter of 2012. Nearly 60,000 medical record requests were requested by survey respondents. Nearly two-thirds of medical records reviewed by RACs did not contain an overpayment, according to the RAC.

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