CMS Changes the Number of Files RACs May Request

Posted on Health Care Law News April 30, 2013 by author

Beginning April 15, 2013, additional documentation limits will be implemented by the Centers for Medicare & Medicaid Services (CMS) for Medicare providers subject to the Medicare Fee-for-Service Recovery Audit Program. More specifically, the maximum documentation requests will be quantified per campus. Campus is defined as one or more facilities under the same Tax Identification Number (TIN) that is located in the same area (using the first three positions of the ZIP) code. The documentation limits are based on the provider’s Medicare claims volume from the previous calendar year as well as the claim type. Recovery Auditors may select up to 75% of any claim type for review and the remaining 25% can be requested from any or all other types.

The maximum number of requests per 45 days is 400, however providers with over $100,000,000 in MS-DRG payments will have a cap of 600. The limit is equal to 2% of all claims submitted for the previous calendar year divided by 8. Recovery Auditors may go more than 45 days between record requests but may not make requests more frequently than every 45 days. 20 records per 45 days may be requested from providers whose calculated limit is 19 additional documentation requests or less. On CMS’s own initiative or by request from the Recovery Auditor, CMS may give Recovery Auditors permission to exceed the limit but CMS or the Recovery Auditor will notify affected providers in writing.