Recovery Auditor - JA DME

CMS awarded Performant Recovery the Region 5, national DME, Recovery Audit Contractor (RAC) contract in late 2016. The RAC programs, was created to identify overpayments/underpayments and to recover improper Medicare payments paid to healthcare providers under Fee-For-Service Medicare plans. Refer to section 302 of the Tax Relief and Health Care Act of 2006.

The program's mission is to identify and reduce Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

How Does the Program Work? - The RAC reviews claims on a post payment basis. They identify specific issues they want to pursue, however are limited to claims approved through the CMS "new issue review" process. In some cases a small number of "non posted issue" requests may be requested from suppliers as the Recovery Auditor requests sample data to supply to CMS on an issue they would like approved. Prior to a widespread review, all approved issues are posted on the Recovery Auditor's website. Noridian urges suppliers to stay informed of the new issues that are identified by the Recovery Auditor for the applicable state. Suppliers are also able to review issues that have not yet been approved. The CMS Provider Resources webpage lists all pending approval issues.

Types of Reviews - There are two types of reviews conducted by the Recovery Auditor:

1. Automated (no medical record needed)
2. Complex (medical record required)

CMS Approved Audit Issues

Upon receipt of a review request, suppliers have 45 days to respond to ensure proper review of documentation. The Recovery Auditor will not review a claim that has previously been reviewed by another entity. They analyze the claim data using their proprietary software and identify claims that clearly contain improper payments. If an improper payment is identified, a demand letter will be issued. Suppliers can identify claims that have been recouped by the Recovery Auditor by checking remits for message code N432.

Recovery Auditor Determinations - Agree or Disagree - Agree or disagree with the Recovery Auditor determination? Check out your options.

Note: The Noridian Supplier Contact Center is only able to answer general questions about the Recovery Auditor program. Suppliers are advised to contact the Recovery Auditor directly with inquires related to their activities.