Cotiviti takes cautious approach to new audits 

SOUTH JORDAN, Utah – Cotiviti, the new Recovery Audit Contractor (RAC) for Regions 3, 4 and 5, recently received approval from the Centers for Medicare and Medicaid Services (CMS) to launch five durable medical equipment (DME)-related audits. But industry experts say the contractor is taking a cautious approach before moving forward. 

Cotiviti, which was awarded the contract in April, now has the green light to audit claims for home oxygen, DME rentals, PAP devices, ventilators and immunosuppressive drugs. 

“They’re not acting on them immediately,” said Andrea Stark, a Medicare consultant and reimbursement consultant for MiraVista, in November. “They’re weighing them.” 

Complexities behind the pause 

A big reason Cotiviti may be holding back, experts say: Home oxygen and ventilator audits will be particularly challenging. During the COVID-19 public health emergency (PHE) documentation requirements were relaxed, which could create confusion. There are also new national coverage determinations (NCDs) for both products. 

Experts have shared those concerns with Cotiviti, and Stark believes that weighed into the contractor’s decision not to rush into the new audits. 

“Our industry is so much more complex,” she said. “Doctor and hospital claims are a larger volume of what they’re used to dealing with.” 

What we know about Cotiviti 

Cotiviti has experience auditing state Medicaid programs, but its track record there has drawn criticism, says Kelly Grahovac, general manager of The van Halem Group. 

“My hope is that their auditors have some knowledge of DME,” she said. “One of the biggest issues we often see when a new audit contractor takes over is that their reviewers seem to be lacking in knowledge and understanding on the claims they’re reviewing.”   

Cotiviti also has a reputation for aggressively pursuing refunds, Grahovac says. 

“It might be different with Medicare fee-for-service, where there is a clear appeals path,” she said. 

How providers should prepare 

While the timeline for the new audits remains unclear, experts advise providers to: 

• Refamiliarize themselves with the coverage determinations and policy articles; 
• Register for Cotiviti’s portal, update your contact details and start poking around; and 
• Prepare to respond to audits with organized documentation, including separator sheets or detailed cover letters. 

“You want to help the auditors to have a better chance of success and decrease the likelihood that the supplier will have to escalate appeals,” Stark said.