Corporate Compliance

Note from the instructor: CMS Revises Audit Timeframes and Reminds Auditors of Quality Obligations

Medicare Insider, October 28, 2014

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This week’s note from the instructor is written by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.  
This week CMS issued a transmittal changing the audit timeframe for complex reviews from 60 to 30 days for some MAC and Recovery Audit Contractor (RAC) reviews. The change could significantly affect the volume and timeliness of complex reviews for providers. The transmittal also contained a number of other “Business Requirements” reminding auditors of requirements related to the quality of their determinations.
CMS changed the timeframe for MAC complex pre-payment reviews and RAC complex post-payment reviews to 30 days when providers submit documents within the prescribed 45 days following the advanced development request (ADR). The transmittal did not affect MAC post-payment reviews or reviews by other contractors. Presumably, the transmittal also did not affect pre-payment reviews by RACs under the pre-payment demonstration, although they were not addressed specifically in the transmittal.
Contractors must make and document their review determination within 30 days. In addition to making their determination, the MAC must enter the determination in the Fiscal Intermediary Shared System and the RAC must communicate their determination to the provider within the allowed 30 day timeframe. If the determination is affected by state laws requiring an evidentiary hearing for the beneficiary, the contractor should review the claim within 30 days, conduct the hearing, and then “continue with processing the claim” on the next day.
The 30 days are counted from when the records are received in the contractor’s mail room. Additional funding is not being provided for the MACs, so according to the transmittal they will have to “adjust their medical review strategy and medical review workloads” to meet the requirements. Not only will this change significantly increase the timeliness of complex reviews for providers, but MACs may do fewer reviews overall in order for their current staff to complete reviews in the required new timeframe. Their only other option would be to hire more reviewers; however, with no additional funding being provided, it is unlikely MACs will want to increase staff.
Speaking of staff, the transmittal also addresses the credentials of the review staff of RACs and Supplemental Medical Review Contractors (SMRCs), reminding them to comply with their Statements of Work (SOW). The transmittal also reminds RACs and SMRCs to follow the requirements from their SOW for consulting other healthcare professionals.
The “Business Requirements” discuss the establishment of a QI process by the RAC, SMRC and Comprehensive Error Rate Testing (CERT) contractors. The QI process should verify “the accuracy of MR decisions” and include inter-rater reliability assessments that must be reported as required by CMS. The transmittal also reminds auditors, including the RAC, CERT, SMRC and Zone Program Integrity Contractors (ZPICs) that they must request ABNs in situations where an ABN is mandatory. 
Overall the transmittal seems to be directed at improving the complex medical review process for providers, in terms of timeliness, quality and, indirectly, volume.

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