Medicare / Medi-Cal News

Don't forget to check Medicare patients' eligibility! Traditional Medicare doesn't require much pre-authorization, but Medicare HMO's often do. Medicare could deny your claim if your patient switches to an HMO, then the HMO could deny your claim because you didn't have prior authorization.

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to






RACs Are on Hold

As of March 1, the current RACs may no longer send additional documentation requests (ADRs) to providers. Recovery auditors may conduct automated reviews through June 1, and may complete review for the ADRs sent as of Feb. 28.

CMS has yet to issue a request for new contracts, but has extended the current contracts until the end of 2015. The extension is meant to allow contractors to process a huge backlog of outstanding appeals. CMS previously suspended appeals to administrative law judges of decisions from RACs for two years, so as to clear over 350,000 outstanding claims.

CMS has stated that the pause will allow it "to continue to refine and improve the Medicare Recovery Audit Program." For instance, the agency "is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between recovery auditors and providers. CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders."

CMS has already announced changes to the RAC program, including:

  • Recovery Auditors must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustment. Providers will not have to choose between initiating a discussion and an appeal.
  • Recovery Auditors must confirm receipt of a discussion request within three days.
  • Recovery Auditors must wait until the second level of appeal is exhausted before they receive their contingency fee.
  • CMS is establishing revised ADR limits that will be diversified across different claim types (e.g. inpatient, outpatient).
  • CMS will require Recovery Auditors to adjust the ADR limits in accordance with a provider's denial rate providers with low denial rates will have lower ADR limits while provider with high denial rates will have higher ADR limits.

In the meantime, an even thought ADRs will cease for the near future, providers can't totally relax. The RACs currently have a three-year look-back period. Any future contractors may look back to claims filed during the current lull. Just because the RACs aren't active now, doesn't mean you won't someday be audited for services provided during this time.

Source: AAPC