CMS update lets auditors request more documents

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Recovery audit contractors would be allowed to request additional documents from providers with high Medicare claim denial rates, the Centers for Medicare & Medicaid Services said last week.

In an update released May 3, CMS said providers' denial rates — the number of claims containing improper payments divided by the total number of reviewed claims — will be used to calculate their adjusted additional document request limit every three 45-day review cycles.

For providers with a denial range between 0% and 3%, they'll receive no additional document reviews for the next three cycles. The adjusted limits top out at 5% for providers with denial rates between 91% and 100%.

The baseline annual document request limit, which became effective on January 1, will remain at 0.5%, CMS said. That baseline — a drop from the previous 2% limit — raised concerns among officials who said the lowered limits would “significant” decrease the contractors' auditing ability.

Kristin Walter, spokeswoman for the Council for Medicare Integrity, said group is pleased with the updates, which show CMS' willingness to “recommit to vital Medicare auditing efforts.”

“It's appropriate that providers with high levels of improperly billed claims receive greater audit focus,” Walter said in a statement to McKnight's. “However, we must ensure that we can significantly reduce the improper payment rate and close loopholes that are allowing some to game the system. We hope to continue to see Medicare stepping forward to give greater scrutiny to those who consistently misbill the program.”

Nearly $43 billion is lost each year to improper Medicare payments, Walter added. Medicare's Recovery Audit Program identified and recovered more than 1.1 million improper claims worth $2.57 billion in fiscal year 2013, CMS said in an October report.