AOPA’s Concerns Prompts CMS to Modify Limits for RAC Audits

AOPA’s continuing conversation and efforts to convince CMS of the cash flow killing harm to patient care and member patient care facilities imposed by the pervasive and aggressive RAC audits together with aggressive AOPA member advocacy with their legislators flowing from the Policy Forum appears to have borne some fruit.

The Centers for Medicare and Medicaid Services has announced that, effective April 3, 2013, it has modified the number of Additional Documentation Requests (ADRs) that a RAC auditor may make for DMEPOS suppliers.

For most DMEPOS suppliers, the limits remain unchanged from last year. The number of ADRs a RAC may make per 45 days is limited to 10% of all claims submitted under a single Tax ID for the previous calendar year, divided by 8.

For suppliers who are classified in categories 52, 53, 56, or 57 however, there is a limit of no more than 10 ADR requests per 45 days. The provider taxonomy codes mentioned above are defined as follows:

  • 52—Medical Supply Company with Prosthetist
  • 53—Medical Supply Company with Orthotist-Prosthetist
  • 56—Individual Certified Prosthetist
  • 57—Individual Certified Prosthetist-Orthotist

The fact that CMS has modified the RAC ADR guidelines to include a limit of no more than 10 ADR requests for claims from companies providing prosthetics is a significant development in AOPA’s efforts to challenge the egregious and aggressive audit practices that RAC auditors have been using. While it does not represent, in any respect, a comprehensive solution to the challenges that RAC audits represent, it does represent an acknowledgement of the negative impact RAC audits have had on the provision of medically necessary services by qualified O&P professionals.

AOPA has contacted CMS and requested that they also consider a similar limit of no more than 10 ADRs per 45 days for suppliers classified as follows:

  • 51—Medical Supply Company with Orthotist
  • 55—Individual Certified Orthotist

CMS has indicated that it will consider including these categories in a future update to the RAC ADR limits. If and when this change is made, AOPA will notify its membership.

AOPA can assist members to ensure that their organization is enrolled in Medicare under the proper provider taxonomy code. Questions on how to do this or any other questions regarding this issue may be directed to Joe McTernan or Devon Bernard.
This action is distinct from CMS’ response to AOPA’s letter of March 8, referenced in a prior AOPA Smartbrief, notifying CMS that Performant Recovery, Inc., the Jurisdiction A RAC contractor, was incorrectly applying the provider based ADR limit calculation to O&P suppliers resulting in more ADR requests than regulations allow. CMS has corrected this situation and Performant Recovery has rescinded RAC audits that exceeded the limits of the supplier based calculation. If you are interested in reviewing those communications, they are accessible at: March 8th letter & CMS Response.