NEWS: May 24, 2017
How to Respond to Lower Document Request Limits
One of the most significant changes in the latest iteration of the Recovery Audit (RA) program is the new limits placed on ADR requests. These limits are based on the number of claims paid by the provider the previous year, with the annual limit equaling one-half of one percent (0.5%) of the total paid Medicare claims. This should come as a relief to many providers, as managing the process of pulling records and submitting them to the contractors in a timely fashion can be an onerous and expensive process.

While RA request limits have gone down, the burden of capturing, responding to and keeping organized all the required and supporting documentation has not. With these new limits in place, the opportunity exists to re-evaluate the overall audit response process, paying specific attention to evaluating the tools currently utilized to support staff. Ultimately, managers have to balance between implementing effective strategies to get the job done and the corporate mantra to always strive to "do more, with less."

Larger health systems may still require fully staffed teams and a comprehensive audit response solution to effectively manage documentation collection and submission. For some smaller providers, however, these diminished request limits may dramatically reduce the number of individuals needed to support this process, and provide an opportunity to implement more streamlined processes and specific tools. We recommend following a few simple steps to determine which approach works best for your organization:

  1. Decide if you should use internal resources or an external vendor to support this process. There are many Release of Information (ROI) vendors that offer services in the field of audit response and documentation submission.

  2. Determine the staffing needs to support your approach, particularly if you choose to support this process with internal resources. The lower documentation request limits should translate into less staffing needs.

  3. Select and implement the most efficient process and tools available. We strongly recommend taking advantage of CMS'' esMD program for electronic document submission. This approach will lower your overall cost of submission and will compress the audit cycle time. The esMD process is the preferred method to receive documents by the audit contractors and is analogous to sending email over fax or letters and packages in the U.S. Mail.

Hospitals can access the esMD gateway directly, but it may be easier to contract with a Certified Health Information Handler (HIH) to assist you with this process.

Our final recommendation would be to build some flexibility into any process you choose to implement. We are navigating a time of change within the healthcare market—and no one would be surprised if the Recovery Audit program continued to evolve over the next few years.

NEWS: April 04, 2017
Changes to the Medicare Recovery Audit Program
A new season of Medicare Recovery Audit Contractor (RA) audits began last month, bringing with it changes for both providers and RA contractors. As many Medicare providers across the country are resuming their audit management activities, let''s take a look at some of the key changes to the RA audit process that took effect this year.

  • Claims Eligible for Review. As in prior audits, RAs will be reviewing Medicare fee-for-service, Part A and Part B, claims over a rolling three-year period based on date of payment NOT date of service. RAs are not permitted to review short-stay inpatient hospital claims; reviews for these types of claims will be limited to a six-month look-back period once the RAs are permitted to review them. The Quality Improvement Organization (QIO) are still authorized by the Centers for Medicare & Medicaid Services (CMS) to conduct sample reviews of these claims. If the QIO identifies a provider with high error rates in patient status, the provider may be referred to the appropriate RA for provider-specific audits.
  • New ADR Limits. New annual ADR limits went into effect Jan. 1, 2017, restricting the number of claims an RA can review for each provider per year. These limits are based on the number of claims paid the previous year, with the annual limit equaling one-half of one percent (0.5%) of the provider''s total paid Medicare claims. RAs may not send ADR requests more frequently than 45 days. To determine the limit per 45-day cycle, the annual ADR limit is divided by eight. A provider''s ADR limit is posted on their RA''s provider portal.
  • ADR Limits applied to Claim Type. RAs are now required to diversify the claim types they are reviewing. To accomplish this, the annual ADR limit of 0.5% is applied to type of claim. The goal of this change is to ensure RAs are not focusing on reviewing only high-dollar inpatient claims.
  • Adjustable ADR Limits based on Performance. CMS has said that it will adjust ADR limits based on providers'' denial rates. Those with better performance will carry lower ADR limits, while those with higher denial rates will carry higher ADR limits. While this was not a formal guideline in years'' past, it did tend to occur as a result of the program''s structure, with RAs focusing on providers that performed poorly rather than those that demonstrated higher compliance with Medicare billing rules.
  • Changes to Timelines for Complex Reviews. RAs now have half the time to complete complex reviews and notify providers, with timelines going from 60 days down to 30. If they do not meet this requirement, they will not be paid for the review. In addition, RAs must wait 30 days before sending the denied claim to Medicare Administrative Contractor (MAC), rather than sending it to MAC and the provider at the same time. This means providers will have the standard 30 days to request discussion with the RA but they no longer need to submit a Redetermination Request during that same timeframe. This change will prevent the extra step of withdrawing those Redetermination Requests based on the outcome of the discussion period. Now, MACs will be notified after a discussion period has ended.
  • New RA Accuracy Standards. CMS has announced that RAs are now held accountable to established accuracy standards. RAs must achieve an accuracy rate of 95 percent, leaving only a 5 percent margin for error. In addition, CMS has established that less than 10 percent of claims should be overturned at the first level of appeal. Consequences to the RA of failing to meet these requirements include decreased ADR limits and/or the elimination of certain reviews until these issues have been addressed and accuracy standards achieved.

While these changes are designed to promote increased objectivity in the RA audit process, the results remain to be seen. But one thing is certain: RA audits will continue to be fluid. For providers, the best practice approach will be a flexible audit management process that can seamlessly adapt to industry changes.

NEWS: June 17, 2016
Best Practice - Identifying the Right Audit Management Solution
Hospitals today need a solution that provides a strong foundation for its audit management process—a solution that enables an integrated, streamlined approach; seamless data sharing; and automated workflows. Manual work that requires significant staff time plagues existing processes and often times is the result of the audit software not “talking” to other systems.

Identifying a scalable solution is also critical. With organizational expansion becoming more commonplace, the ability to onboard new facilities to a consolidated audit management process is now a core requirement. Ensuring an easy and painless transition for the end-users is essential for success.

Beyond the technical requirements of a new solution, hospitals need the support of a technology solutions provider that understands the complexity of the audit landscape and can facilitate the continued evolution of required processes. This means finding an expert vendor that has the ability to look ahead, identify potential impacts on the workflows and proactively make appropriate system enhancements to continue to drive efficiency and results.

Technical Requirements to Consider

  • Integration of applicable systems. Every system or vendor used in managing the RAC process needs to be directly connected.
  • Real-time appeal tracking. A system that can generate real-time, automated worklists for staff and calculate due dates at all levels of appeal.
  • Electronic document repository for all correspondence including complete medical records.
  • Financial Reporting. A tool with a strong financial reporting component. Hospitals need to accurately report on denied dollars, including dollars at-risk versus dollars that have already been recouped from the facility.

To Evaluate Solutions – Key is to identify user requirements and validate vendor deliverables.

  • Proof of concept to mitigate risks; consider sending vendor several months' worth of claims and remittance data to test the system.
  • Require strong client references and speak to those references.
  • Keep in mind the vendors or systems requiring interfaces.

Contact us today for more information about selecting the right Audit Solution for your organization.

NEWS: May 05, 2016
State of the RAC: May 2016
Below is the first in a new series of “State of the RAC” messages from Stewart Presser, Vice President of Health Finance and Membership Services with the Greater New York Hospital Association (GNYHA). Stewart is an industry expert and noted speaker on the Recovery Audit program.

Additional Documentation Requests Update
CMS has modified the Additional Documentation Requests (ADRs) limits. Moving forward, each provider's annual limit will be based on the number of Medicare claims paid in the previous year that are associated with their 6-digit CMS Certification Number (CNN) and the Provider's National Provider Identifier (NPI) number.
  • The annual ADR limit will be calculated on half of one percent (0.05%) of the provider's total number of paid Medicare Fee-for-service claims from the previous year.
  • ADR letters are sent to providers by the RAs on a 45-day cycle. The annual ADR limit will be divided by 8 to establish the ADR cycle limit, which is the maximum number of claims that can be included in a single 45-day period.
For Example:
  • Provider A billed, and was paid for 22,500 Medicare claims in 2014. The provider's ADR limit would be 22,500 X .0005 which equals 112.65. This is the total amount of ADRs the provider can receive in the year. The limit of 112.65 is then divided by 8 cycles to determine the amount of ADRs per 45 day cycle. This would result in 14 ADRs every 45 days for this provider.
ADR limits will be diversified across all claim types for each facility, based on the type of bill (TOB) that the provider was paid for in the previous year. So if the provider submitted TOB 11x, 12x and 13x the ADRs would be apportioned over the TOBs based on the volume in each TOB.

RAs will post providers new ADR limits on the RA provider portal.

CMS will adjust a provider's ADR limit based on the provider's compliance with Medicare rules. CMS states that providers with low denial rates will have ADR limits decreased, while providers with high denial rates will have their ADR limits increased. CMS states that they reserve the right to establish a different record limit when directing the RAs to conduct reviews of specific topics or providers.

Providers can submit questions to CMS concerning ADR limits via email to

NEWS: March 11, 2016
Bluemark and GNYHA Ventures to exhibit at the Compliance Institute April 17-20
Visit Bluemark and the Greater New York Hospital Association at this years' Compliance Institute at the Aria hotel in Las Vegas on April 17th through the 20th. Each year the Institute brings together healthcare compliance leaders from across the county to learn, share and connect. We will be in the exhibit hall in booth 502 and will be talking about the latest version of our industry leading audit management solution Blueway Tracker. Our solution provides state-of-the-art functionality to manage the time-sensitive and burdensome demands that audit responses require. Increase your productivity with integration of 835/837 data and electronic submission of medical records via esMD.

Learn why over 300 hospitals have chosen Blueway Tracker to protect their revenue stream.

PRESS RELEASE: December 15, 2015
Ractracker Website Announcement
The Greater New York Hospital Association and Bluemark are excited to announce the launch of our newly designed Blueway Tracker website, This new site includes our updated logo and design elements and will continue to be the homepage where our customers will access the solution. The modern design should not only improve the overall users' experience but will also make product information more accessible. Our goal is to provide our clients and website visitors with the most accurate up to date product information, and share our knowledge and expertise in the field of Audit Management. Read more (PDF).

Bluemark Welcomes Steve Mullin as EVP Sales & Marketing
Steve Mullin Announcement for Website Bluemark is pleased to announce the hiring of Steve Mullin as Executive Vice President of Sales and Marketing. In this newly created role, Steve will lead the company's sales and marketing initiatives plus collaborate with the development team on future products. This addition aligns with an overall corporate strategy to grow the company by further leveraging existing partnerships and by being more aggressive in creating direct sales channels within key markets. As a member of the Executive Team, Steve will be working closely with the company's partners on developing and executing key initiatives to drive the company's growth strategy. Read more (PDF).

More news & updates coming soon!