Sec. 4. Greater transparency of recovery auditor performance
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Section 1893(h) of the Social Security Act ( 42 U.S.C. 1395ddd(h) ), as amended by section 3(a), is further amended by adding at the end the following new paragraph: With respect to each recovery audit contractor with a contract under this section for a contract year, the Secretary shall publish on the Internet website of the Centers for Medicare & Medicaid Services the following information with respect to the performance of each such recovery audit contractor: With respect to the performance of each such recovery audit contractor during a contract year, the Secretary shall post on such Internet website the following information:
The aggregate number of claims audited by the recovery audit contractor during the contract year involved, as well as the number of audits of each of the following audit types (each in this paragraph referred to as an audit type ): Automated. Complex. Medical necessity review. Part A claims. Part B claims. Durable medical equipment claims. Part A medical necessity. The aggregate number of requests for medical records, referred to as additional documentation requests, for each audit type during the contract year involved.
The aggregate number of denials for each audit type made by the recovery audit contractor during the contract year involved. The denial rate of the recovery audit contractor during the contract year involved for part A claims, part B claims, and durable medical equipment claims for each audit type during the contract year involved. The aggregate number of appeals filed by providers of services and suppliers with respect to denials for each audit type made by the recovery audit contractor during the contract year involved.
The aggregate rate of appeals filed by providers of services and suppliers with respect to denials for each audit type made by the recovery audit contractor during the contract year involved. For claims denied by a recovery audit contractor, the number of claims during the contract year that were appealed by the provider, the number of concluded appeals that did not advance to a subsequent appeals stage, and the number and percentage of completed appeals that were decided in favor of the provider, for each level of appeal as follows:
Reconsideration by the relevant medicare contractor. Redetermination by a qualified independent contractor. Administrative law judge hearing. Medicare Appeals Council review. United States District Court judicial review. The net denials for each audit type, calculated as the number of denials for such audit type under clause
(iii)minus the number of such denials that are overturned on appeal and the net denial rate for each audit type, calculated in the same manner as denial rates under clause
(iv)but subtracting from denials those denials that are overturned on appeal. The Secretary shall make available on such Internet website the results of any performance evaluation with respect to each recovery audit contractor conducted by an independent entity selected by the Secretary for such purpose. Each performance evaluation shall include in its results for posting on such Internet website a determination of annual error rates of the recovery audit contractor for each audit type and the net denials and net denial rates described in subparagraph (A)(viii). . The amendment made by subsection
(a)shall apply to contracts entered into or renewed with recovery audit contractors under section 1893(h) of the Social Security Act ( 42 U.S.C. 1395ddd(h) ) on or after the date of the enactment of this Act.
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Sec. 4
Greater transparency of recovery auditor performance
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