Recovery Auditor Prepayment Review Demos Imminent

"Our challenge," says Focke, "is to ensure that all physician documentation has been completed before sending the record," she says. "We are currently reviewing our internal medical staff rules and regulations regarding documentation time frames. If the record is not complete, we experience a delay and our cash flow may be compromised".

As far as the issues for which her facility has received additional documentation requests (ADRs), Focke says that it has predominantly been short-day stays and cardiac procedures, and that these issues and more should be monitored closely.
"Kentucky is not included in the RAC prepayment demonstration program, but as of now, our MAC is taking on this role," she says. "One thing we found difficult is that prepayment record requests do not always arrive timely. Every Monday we look at the Medicare online system to see if there have been suspended claims (SB6001) for pre-payment review. We compare this suspend list with the letters received and if there are letters missing, we print them from the system and process accordingly."

From an operational standpoint, ADR will come from the FI/MAC and will contain specific details regarding where providers should submit documentation. From here, providers will have 30 days to submit and the claim will automatically be denied if documentation isn't received within 45 days.

Once the Recovery Auditor receives the documentation, it will then review the claim and communicate its determination back to the FI/MAC, according to CMS. Providers will then receive the payment determination on the remittance advice within 45 days.