Updated on: April 25, 2013

Medical Records Recovery Auditor Minimum Limits Have Changed

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Original story posted on: April 16, 2013

Yes, you did read that headline right!  CMS announced that effective April 15, 2013 the minimum number of records that the Recovery Auditors (RACs) may request has been reduced for hospitals providers. 

Some highlights as it pertains to hospital campuses:

  1. The minimum number of requests per 45 days is being reduced from 35 to 20 for providers who have a calculated limit of 19 or less.
  2. Only 75 percent of one claim type may be requested every 45 days as noted below in the comparative table provided by CMS in the update notification.

Old

New

Campus Concept

Campus Concept

100% of any claim type

75% Limit on any particular claim type

400 ADR cap /maximum every 45 days

400 ADR cap /maximum every 45 days

 

• If >$100M annual revenue, then 600

 

 

• If >$100M annual revenue, then 600

 

35 minimum record request

20 minimum record request

2% of Medicare claims volume

2% of Medicare claims volume

Exceptions allowed

Exceptions allowed

In the updated memorandum, CMS noted that they may give the Recovery Auditors permission to exceed the limit. Permission to exceed the limit may occur by CMS’s own initiative or from the Recovery Auditor requesting permission. CMS or the Recovery Auditor will notify affected providers in writing.  

CMS also posted update on ADR limits for DME Suppliers effective April 15, 2013.  Limits for physicians (including other providers such as therapists) remain the same.

Monitor Monday will continue to see if listeners notice a difference in ADR requests based upon the new minimums. Monitor Monday RAC experts have told us that we may have to look long and hard for those hospitals that have only been receiving the minimum number of requests.

About the Author

Nancy Beckley, president of Nancy Beckley & Associates LLC, is certified in healthcare compliance and has extensive experience specializing in rehabilitation and compliance. Her work includes establishing auditing and monitoring protocols for outpatient providers; conducting pre-acquisition compliance risk audits; strategic market-based planning and analysis; operational analysis, including benchmarking, coding and staffing; CORF development and implementation; managed care analysis; facilitation of credentialing, and managed care contract technical review. 

Contact the Author

nancy@nancybeckley.com

To comment on this article please go to editor@racmonitor.com

Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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