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  • CMS Transition Means Temporary Changes to Manual Medical Review Processes

    The Centers for Medicare and Medicaid Service's (CMS) transition to new recovery audit program contracts will temporarily change pre- and postpayment manual medical review processes for therapy services over $3,700, and will likely create delays in the typical 10-day review cycle.

    CMS is procuring the next round of recovery audit program contracts, and the agency is planning "a pause in operations" while old contracts are closed out and new ones started. The pause will have different ramifications depending on whether a particular state is subject to prepayment review or postpayment review of therapy services exceeding $3,700.

    In postpayment states, February 21, 2014, was the last day that Additional Documentation Request Letters (ADR) for postpayment review were sent to providers. In prepayment states, February 28 is the last day that Medicare administrative contractors will send out letters for prepayment reviews of therapy claims until new contracts are awarded. After February 28, prepayment reviews will not be conducted; instead all claims will undergo postpayment review after the new contracts are in place. Because of the volume of claims CMS anticipates will accumulate during the transition, the 10-day reviewing timeframe will not apply to these reviews. The new recovery auditors will review claims in the order that they were paid.

    If a provider has received an ADR letter, the provider must comply with the request and submit the records. Any records that were previously submitted to the recovery auditor will continue to be reviewed, and the provider will receive a review results letter, as usual. Providers can monitor progress of the transition at the CMS Recovery Audit Program Recent Updates webpage.

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