American Speech-Language-Hearing Association

Preparing for Medicare Recovery Audits

(April 16, 2013)

ASHA has created two webpages to assist members in finding their Medicare Recovery Audit Contractors (RACs) and understanding the audit process.

Background

Audiologists and speech-language pathologists may find themselves subject to a Medicare recovery audit as Congressional attention and funding focus on the prevention of Medicare fraud, waste, and abuse. In 2011, RACs identified and corrected 887,291 claims for improper payments, including $797.4 million in overpayments and $141.9 million in underpayments repaid to providers. RACs have implemented the Electronic Submission of Medical Documentation (esMD) System in order for providers to electronically submit and track their medical reviews.

Use of RACs for Manual Medical Review of Therapy Services

All speech-language pathologists who submit Medicare Part B claims exceeding the $3,700 threshold for total physical therapy/speech-language pathology services for an individual during the calendar year will be subject to review by the Medicare RAC based on the new manual medical review process (MMR). The MMR process that utilizes the RACs is applicable to claims submitted for dates of service on or after April 1, 2013.

The Medicare Administrative Contractors (MACs) will refer each claim for therapy services over the $3,700 threshold to the RACs for pre or postpayment review. The prepayment review applies to 11 states (California, Florida, Illinois, Louisiana, Michigan, Missouri, North Carolina, New York, Ohio, North Carolina, and Texas). Claims from the remaining states and territories will undergo postpayment review. Because all claims exceeding $3,700 will be reviewed, CMS has exempted therapy manual medical reviews from the standard limits of additional documentation requirement (ADR) limits, which prohibit RACs from frequent or excessive ADRs. Additionally, the 10-day requirement mandated in the legislation will be applied by conducting manual medical review within 10 business days for the prepayment review and completing the postpayment review within 10 business days of receiving the medical record. This final clarification resulted from advocacy efforts by ASHA and several other therapy and hospital organizations.

CMS Resources

ASHA Resources

For questions, contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at lsatterfield@asha.org or a member of the health care economics and advocacy team at reimbursement@asha.org.


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