Types of Reviews

There are three types of RA Audits:  Automated Review, Complex Review and Semi-Automated Review.   The RA can review retroactively up to three years of provider claims but cannot review any claims prior to October 1, 2007. 

Automated Review
This type of review occurs when the provider receives a demand letter for repayment from the RA. There is no prior review of the medical record prior to receiving the demand letter. Therefore, the recoupment is automatic. The provider has 30 days to dispute the RA findings. If after 30 days the provider does not successfully dispute the findings, the FI/MAC will offset the overpayment. 

Complex Review
The Complex Review is the actual physical review of the Medical Record or other documentation where the RA contractor individually reviews the medical record. Under a complex review, the RA communicates all results directly to the provider including results where no improper payment was identified. When there has been an improper payment, the RA must inform the provider of which coverage, coding, payment policy or article was violated. 

Semi-Automated Review
The Semi-Automated Review consists of two parts.  During the first part, which is the automated review process, the deviation in the billing process identified. During the second part, the RA sends a demand letter to the provider with an explanation of the billing error.  The provider then has 45 days to submit evidence to the RA. 

There are two possible outcomes of the semi-automated review:

• If the provider sends documentation, and the documentation refutes the RA claim, then the claim will not be sent for an adjustment and the provider will be notified that the case is closed.
• If the provider does not submit documentation, or the submitted documentation does not refute the claim, then the claim will be sent to the Medicare Claims Processing for adjustment and a follow-up demand letter will be sent to the provider.