Audit and Compliance



A&C May

One of the most significant changes in the latest iteration of the Recovery Audit (RA) program is the new limits placed on ADR requests. These limits are based on the number of claims paid by the provider the previous year, with the annual limit equaling one-half of one percent (0.5%) of the total paid Medicare claims. This should come as a relief to many providers, as managing the process of pulling records and submitting them to the contractors in a timely fashion can be an onerous and expensive process.

While RA request limits have gone down, the burden of capturing, responding to and keeping organized all the required and supporting documentation has not. With these new limits in place, the opportunity exists to re-evaluate the overall audit response process, paying specific attention to evaluating the tools currently utilized to support staff. Ultimately, managers have to balance between implementing effective strategies to get the job done and the corporate mantra to always strive to "do more, with less."

Larger health systems may still require fully staffed teams and a comprehensive audit response solution to effectively manage documentation collection and submission. For some smaller providers, however, these diminished request limits may dramatically reduce the number of individuals needed to support this process, and provide an opportunity to implement more streamlined processes and specific tools. We recommend following a few simple steps to determine which approach works best for your organization:

  1. Decide if you should use internal resources or an external vendor to support this process. There are many Release of Information (ROI) vendors that offer services in the field of audit response and documentation submission.

  2. Determine the staffing needs to support your approach, particularly if you choose to support this process with internal resources. The lower documentation request limits should translate into less staffing needs.

  3. Select and implement the most efficient process and tools available. We strongly recommend taking advantage of CMS' esMD program for electronic document submission. This approach will lower your overall cost of submission and will compress the audit cycle time. The esMD process is the preferred method to receive documents by the audit contractors and is analogous to sending email over fax or letters and packages in the U.S. Mail.

Hospitals can access the esMD gateway directly, but it may be easier to contract with a Certified Health Information Handler (HIH) to assist you with this process.

Our final recommendation would be to build some flexibility into any process you choose to implement. We are navigating a time of change within the healthcare market—and no one would be surprised if the Recovery Audit program continued to evolve over the next few years.