CMS is in the procurement process for the next round of Recovery Audit (RA) Program contractors and as a result, announced on February 18, 2014, that it will “pause” RA activities.  This will allow the RAs time to wind down and complete unfinished projects by the time their contract expires June 1, 2014.

NASL reports participating in a call this week with CMS Provider Compliance Group staff regarding the Manual Medical Review (MMR) process’ ongoing issues.  The Provider Compliance Group staff indicated that during the RA pause, Medicare Administrative Contractors (MACs) have the authority to review claims for reasonableness and medical necessity at any time and claims above $3,700 are no exception.

So, will those therapy claims above $3,700 get paid?  As far as we know the interpretation is yes. Those of us in pre-payment states may feel a bit of relief, however, don’t forget that any claim is open to post-payment review by the MAC at any time.

Because the RA procurement process has many steps, it is unknown how long the “pause” will last, because CMS doesn’t know when the new RA contractors will begin.  CMS’ RAC Pause Announcement

Important dates to remember:

  • 2/21/14: last day a Recovery Auditor could send a post-payment ADR
  • 2/28/14: last day a MAC could send prepayment ADRs to the Recovery Auditor Prepayment Review Demonstration
  • 6/1/14: last day Recovery Auditor may send improper payment files to the MACs for payment adjustment

Providers should receive payment or demand letters on all ADRs per the dates above. The therapy cap website has not been updated by CMS reflecting the above information.  CMS had anticipated that Congress would have acted by now regarding the March 31st expiration of the Medicare Part B exceptions process. CMS has not yet indicated when we can expect the therapy cap updates on their website.