Audit and Compliance



A&C DEC 2017

As we approach the end of 2017, we thought it would be helpful to remind providers how the Centers for Medicare & Medicaid Services (CMS) calculates a provider's Additional Documentation Requests (ADRs). On May 4, 2016, CMS published the ADR limit instructions for institutional providers on its website. Since these new guidelines have been in effect, hospital providers have experienced a reduction in the number of ADRs as compared to the "old" RA program. CMS will publish new provider ADR limits for 2018 based on provider claim volume, and the RAs will post the new ADR limits on their websites under the provider portal.

On Nov. 13, CMS began posting a list of review topics that have been proposed, but not yet approved, for RAs to review. These topics will be listed on a monthly basis on the CMS Provider Resources page. The following is a sample of what the listing contains for one proposed audit campaign. The full listing is available here.

Topics proposed for RAC review
Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary

  • Description: Review of Pre-admission screening, post-admission examination, and other requirements for IRF Stays
  • State(s)/MAC regions where reviews will occur: All states
  • Review type: Complex Review
  • Provider type: Rehabilitation Facility (IRF)
  • Affected code(s): Not code-specific
  • Applicable policy references: 42 Code of Federal Regulations (C.F.R.) §§412.604-412.622 CMS IOM 100-02 Chapter 1 §110

We recommend providers establish a process to review these CMS postings on a monthly basis so that you are aware of what new audit campaigns may impact your facility. In addition to providers reviewing the list of proposed audit campaigns, we encourage you to review your RA's provider portal for approved audit campaigns so that you will be ready in the event you start to receive audit letters/ADRs.