CMS kick-starts new audit program

Friday, January 9, 2015

WASHINGTON – A sweeping new program to identify overpayments specifically for DME, home health and hospice is underway.

CMS announced on Dec. 30, amid the quiet of the holidays, that it selected Connolly as the recovery audit contractor (RAC) to oversee the national program.

“The announcement came a lot earlier than I thought,” said Wayne van Halem, president of the van Halem Group. “I thought we’d have until mid-2015.”

Wilton, Conn.-based Connolly is already the RAC for Jurisdiction C, the largest of the four jurisdictions.

With Connolly’s background, industry stakeholders suspect it will be up and running in no time, starting with the reviews it already has in the pipeline. Those include a number of automated reviews, and complex reviews for power mobility devices and lower limb prostheses.

“From there, they’re going to start looking at other high-dollar items,” van Halem said. “When I think about where there’s a lot of money being spent, I think of vents.”

Connolly has neither the best nor the worst reputation among the RACs, stakeholders say.

“When I saw it was Connolly, I don’t want to say I was relieved, but we’ve worked with them in the past and we’re familiar with their processes,” said Sylvia Toscano, owner of Professional Medical Administrators.

One big thing to keep an eye out for when dealing with Connolly, stakeholders say: Historically, the contractor has not made good use of the open discussion period to work with providers before starting the recoupment process.

“In some circumstances, like with high-volume providers, they have a tendency to start taking away money without requesting additional documentation,” said Kelly Wolfe, CEO of Regency Billing and Consulting. “We find a lot of their denials get overturned on appeal.”

The good news, stakeholders say, is that CMS is implementing a number of improvements to the RAC program, starting with Connolly. Those improvements include requiring the RACs to wait 30 days before sending claims to the MACs for adjustment, keeping the RACs from collecting contingency fees until the second level of appeals is exhausted and putting in place a provider relations coordinator.

“We’re very anxious to get these improvements in place,” said Andrea Stark, a reimbursement consultant with MiraVista. “They ensure not only that the RAC is transparent in what it’s doing, but also that it’s auditing with integrity.”