Recovery Auditor &Medicare Administrative Contract Awards

on Tuesday, 27 January 2015. All News Items | Case Management | Patient Status | Medicare Coverage

Who are the Region 5 Recovery Auditor and J-J MAC?

With freezing temperatures and threats of snow in the deep-south, it is hard to believe that it’s time for spring baseball try-outs for my two nephews. With that in mind, trying to keep up with new Recovery Auditor and Medicare Administrative Contractor (MAC) contract awards is about like Costello trying to understanding Abbott in their comedy routine “Who’s on First.” The big question’s being:

  • “Who’s” the current Region 5 Recovery Auditor and Jurisdiction-J MAC; and  
  • “What” issues are they focused on reviewing?

Recovery Auditors

Who is the Region 5 Recovery Auditor?

If you had asked me this question two weeks ago I would have told you Connolly, LLC. However, that was before looking at the CMS Recovery Audit Program web page for updates and finding the January 14, 2015 post that as a result of a post-award protest filed at the Government Accountability Office (GAO), CMS would be delaying commencement of work under this contract.

Who is protesting the award? According to the GAO Bid Protest Docket Entry Filed on January 6, 2015, the Protestor is Performant Recovery, Inc. who is the current Region A Recovery Auditor for CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RA and VT.

What Issues are they Focused on Reviewing?

Region 5 will be a new durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and home health/hospice (HH/H) Recovery Auditor that will be national in its scope. So while, yes there mission is to identify and correct improper payments for DMEPOS, home health and hospice, I believe that specific to DMEPOS there will definitely be a focus on wheelchairs and hospital beds as both had significant improper payment rates in the Comprehensive Error Rate Testing (CERT) Fiscal Year 2014 Report Appendices.

Medicare Administrative Contractors

Who is the Jurisdiction-J (J-J) MAC?

Cahaba, GBA was the Jurisdiction 10 (J-10) MAC for Alabama, Georgia and Tennessee. On September 7, 2014 CMS announced that Cahaba, GBA had again been awarded this MAC Jurisdiction and would become the J-J MAC.

However, less than a month later on October 6, 2014, First Coast Service Options, Inc. submitted a protest to the GAO. At that time, CMS indicated that during the GAO review, that could take several months, Cahaba would continue to perform A/B MAC claims processing-related work under the existing J-10 contract.

A decision regarding this protest was posted to the GAO website on January 8, 2015. The GAO made the Decision to deny the protest. CMS updated their MAC web page on January 20th and indicated that the “stop work order was lifted on January 9, 2015 and CMS will now move forward with the awardee, Cahaba, to implement the new MAC contract.”

What Issues are they Focused on Reviewing?

Here are the reviews on Cahaba’s January 2015 Prepayment Medical Review Log:

Review Description

Bill Type

Edit Number(s)

Inpatient Rehab Facility A0801-A0804

11X

5176K – Alabama

5014R – Georgia

5009N – Tennessee

Neurological CMGs A0601-A0604, D0601-D0604

11X

5197K – Alabama

Inpatient Rehab A2001-A2004

11X

5177K – Alabama

5015R – Georgia

5010N – Tennessee

CPT 83880 – B-type Natriuretic Peptide

14X

5134K – Alabama

5010R – Georgia

5004N – Tennessee

Condition Code 07

11X

5196K – Alabama

5036R – Georgia

5030N – Tennessee

Final Rule CMS 1599-F, 2 Midnight Rule Inpatient Admissions

11X

5PXXX

CPT 99309-subsequent nursing facility care, per day, for the evaluation and management of a patient

71X

5059T – Tennessee

Modifier GW – service not related to the hospice patient’s terminal condition

71X

5060T - Tennessee

So, as it stands today, we may think we know “Who” will ultimately be the Region 5 Recovery Auditor, and CMS has confirmed that Cahaba, GBA will be the J-J MAC. At the end of the day, no matter “Who” is what, I encourage you to check both CMS Contractor web pages on a regular basis.

Quick Links:

CMS Recovery Audit Program Web page: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html

CMS Medicare Administrative Contractors Web page: http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors.html

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-three years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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