CMS places limits on recovery audit contractors in 2010

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The Centers for Medicare & Medicaid Services (CMS) has placed limits on recovery audit contractors (RACs), regarding the number of medical and related claims record requests they may seek from hospitals and other providers during an audit in 2010.

The agency said it made this decision in response to feedback from the RACs, providers/suppliers and their associations. These limits will be set by each RAC on an annual basis to establish a cap per campus on the maximum number of medical records that may be requested per 45-day period.

The limits will be set at 1 percent of all claims submitted for the previous calendar year, and divided into eight periods (45 days). Although the RACs may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days, according to CMS. A provider’s limit will be applied across all claim types, including professional services.

The agency added that the limits are based on submitted claims, irrespective of paid/denied status and/or individual lines, although interim/final bills and RAPs/final claims shall be considered as a unit.

While respecting a provider’s overall limit, CMS said that the “RAC may exercise discretion in the exact composition of an additional documentation request.” For example, the RAC may request inpatient records up to the full limit even though the provider’s inpatient business may only be a small portion of their total claim volume.

As a result, two caps will exist in 2010: Through March 2010, the cap will remain at 200 additional documentation requests per 45 days for all providers/suppliers. However, from April through September 2010, providers/suppliers who bill in excess of 100,000 claims to Medicare will have a cap of 300 additional documentation requests per campus unit, per 45 days.

In addition, in 2010, CMS will allow the RACs to request permission to exceed the cap. “Permission to exceed the cap cannot be requested in the first six months of the fiscal year,” the agency noted.