Revenue Cycle

PSST! CMS says medical necessity, physician complex audits on their way

Recovery Auditor Report, May 13, 2010

On the May 12 RAC 101 call for physicians, a caller asked CMS specific information about when medical necessity and physician reviews would begin. A CMS representative instructed the audience that the physicians are already undergoing automatic reviews but the complex reviews requiring medical record requests won’t begin until CMS posts record requests limits on its RAC website.

In terms of medical necessity audits, according to a CMS representative on the call, at least one RAC has submitted a medical necessity issue to CMS for approval. CMS has not yet approved any proposed medical necessity issues but anticipates doing so in the near future.

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