10/22/12 - Change in Recovery Auditor for Some Providers
If a provider is located in any state other than Missouri, Kansas, Iowa or Nebraska (i.e. Jurisdiction 5 for Wisconsin Physician Services (WPS)), and WPS is their Medicare Administrative Contractor (MAC), there has been a change in their Recovery Auditor. As of 10/22/12 the Recovery Auditor for these providers is HealthData Insights.
This change occurred because the Centers for Medicare & Medicaid Services (CMS) completed a contracting transition involving the MAC. This transition did not impact the provider’s MAC but the transition required the change in the Recovery Auditor.
All impacted providers will be notified by HealthData Insights via postal mail.
All open additional documentation requests and any requests where a demand letter has not been generated were canceled and closed. Claims in process and claims data from the other Recovery Auditors will not be shared with HealthData Insights
Additional questions may be directed to RAC@cms.hhs.gov.
Note: This does not impact providers in Jurisdiction 8 where WPS is also the Medicare Administrative Contractor. The change in Recovery Auditor is only specific to those providers who originally had WPS pay their claims as the national fiscal intermediary.
If you are a provider who is undergoing a RA, you will typically go through the following steps:
1) Receipt of RA demand letter
A RA demand letter is a letter sent to the provider notifying them that an improper payment for the Medicare Program has been identified. This letter contains the following components:
- reason for the improper payment
- amount of the improper payment
- date the improper payment amount should be paid and to whom
- the regulation related to the improper payment
- key timeframes within the process
- how to stop recoupment
- how to refund to avoid interest payment
- where to send appeals and
- details of the discussion period available with the RA.
An Audit Detail is included with the demand letter listing the specifics of the improper payment.
2) Review of materials and refund
You should first review the demand letter, Medicare regulation and audit detail to understand the improper payment determination. To avoid any interest assessment, you should refund the monies within 30 days from the date of the demand letter.
3) Payment and other options
Providers have the option of issuing a check or requesting immediate offset by the Medicare Claims Processing Contractor. You may also have the amount recouped by taking no action after the receipt of the demand letter. If you choose recoupment, interest will be assessed after the 30th day.
If you have additional information or disagree with the demand letter, there are options available to you. You may file a Discussion (with the RA) by following the directions on your demand letter; or, you may file an appeal (with the Medicare Claims Processing Contractor), which if done within 30 days, stops recoupment. Or you may do both −file for a Discussion and an Appeal, at the same time.
Please note: When a provider receives a demand letter, the provider has the opportunity to file a request to discuss the improper payment with the Recovery Auditor. This request must be made in writing and sent to the RA for consideration. The RA will respond within 30 days of the request. In addition, the provider may elect to have their claim escalated to a physician review. This can be done only if the provider’s physician or one employed by the provider requests that the RA physician reviews the claim. Furthermore, if the provider files an appeal with the MAC, the discussion period must be stopped.