The Centers for Medicare and Medicaid Services is getting ready to launch two new data collection programs, affecting providers and their revenue streams by making them further justify claims submitted for payment.

CMS will conduct a demonstration program, called Fee-for-Service Recovery Audit Prepayment Demonstration, to allow Medicare Recovery Auditors to review claims on a pre-payment basis in certain states. The agency also will conduct a demonstration program, called Prior Authorization Demonstration, to establish a prior authorization program for power mobility device claims (electric wheelchairs) in certain states.

Under the pre-payment audit program, contractors will request additional documentation, including medical records, to support submitted claims, according to a notice available here and being published Feb. 7 in the Federal Register. This includes any documentation beyond what is included on the face of the claim that supports the billed item or service. “This supporting information may be requested by CMS and its agents on a routine basis in instances where diagnoses on a claim do not clearly indicate medical necessity, or if there is a suspicion of fraud,” the notice states.

The notice does not indicate the states in which the demonstration program will be conducted. In an earlier notice CMS published in November 2011, the agency said the audits will initially focus on inpatient hospital claims for short stays and be conducted in 11 states: California, Florida, Illinois, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania and Texas.
Under the prior authorization program, documentation to support a claim must be submitted before the power mobility device is delivered. CMS will conduct this demonstration in California, Florida, Illinois, Michigan, New York, North Carolina and Texas.

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