CMS provides status of Recovery Audit Program enhancements

The Recovery Audit Program is undergoing a series of changes to improve the program’s accuracy and to allow providers more opportunities to provide feedback on the process. CMS detailed the recent and ongoing enhancements that it is making to the program, which includes more stringent requirements for recovery audit contractors (RACs) to ensure that they make valid determinations and are held accountable for their decisions.

Provider assistance

CMS has taken steps in assisting providers with compliance matters, including posting compliance tips on its website. CMS also established the Provider Relations Coordinator in order to offer providers the means to efficiently resolve matters that cannot be solved by a RAC.


In order to ensure that RACs are making valid determinations, CMS now requires them to maintain an overturn rate of less than 10 percent at the first level of appeal. The failure to do so will result in the RAC being placed on a corrective action plan. RACs are also required to maintain an accuracy of at least 95 percent, and the failure to do so will result in a progressive reduction of additional documentation request (ADR) limits. Additionally, the look-back period has been limited to six months from the date of service for all patient status reviews when claims are submitted within three months of the date of service. All RACs are required to have a physician Contractor Medical Director who is available to discuss improper payment identifications.

ADR limits

CMS revised the ADR limits for facility claims, which are diversified across all claim types of a facility. Additionally, CMS is not raising the ADR limits for physicians and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers and suppliers. CMS is also establishing ADR limits that are based on a provider’s compliance with Medicare rules.

In progress

CMS is working on developing a Provider Satisfaction Survey, which would give providers an opportunity to provide feedback on the RACs’ performance. Additionally, CMS will provide information about the program through increase public reporting and quality assurance activities so as to allow the provider community to have access to the Recovery Audit Program data.

Additional enhancements

RACs will have 30 days instead of 60 days to complete complex reviews and notify providers of their findings. RACs will also be required to wait 30 days to allow for a discussion request prior to sending a claim to the Medicare administrative contractor (MAC) for adjustment. RACs must also enhance their provider portals and broaden their review topics.

Contingency fees

All new contracts will withhold contingency fees for RACs until after the second level of appeals are exhausted.