A Calm Before the Storm: Updates on CMS Audit Activity

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In February 2014, CMS made two announcements that affect future Medicare audits. First, CMS instructed RACs to stop issuing post-payment additional documentation requests (ADRs) after February 21 and instructed MACs to stop issuing pre-payment ADRs after February 28. In addition to affording CMS the opportunity to make refinements and improvements in the audit process, these suspensions respond to the recent moratorium on scheduling of ALJ hearings imposed by the Office of Medicare Hearings and Appeals.

Second, CMS revised Section 3.2.3 in Chapter 3 of the Medicare Program Integrity Manual [PDF] entitled “Requesting Additional Documentation During Prepayment and Postpayment Review.” The revisions authorize MACs, RACs, and ZPICs to deny, without further request for documentation, other “related” claims that were submitted prior or subsequent to the audited claim if the documentation of the audited claim can be used to validate (or invalidate) the “related” claims. Armed with these revisions that become effective March 6, the alphabet of auditors will no doubt sprint out of the pit stops full speed once the yellow flag is withdrawn by CMS.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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