Monitor Mondays

Prior Authorizations: Problems When in the Wrong Hands

March 07, 2022 Ronald Hirsch, MD | Knicole Emanuel Esq. | David Glaser, Esq. | Tiffany Ferguson | Matthew Albright | Marcy Andersen Season 12 Episode 491
Monitor Mondays
Prior Authorizations: Problems When in the Wrong Hands
Show Notes

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers.  

In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS), it states that generally, claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Uniform Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) may perform reviews based on evidence of potential fraud or gaming, and the Comprehensive Error Rate Testing (CERT) contractor may review a random sample for the purposes of estimating the Medicare improper payment rate. The RAs, however, are not listed as audit contractors allowed to audit these claims – nor should they be. So why are providers receiving audit requests for these services from their Recovery Auditors?

Reporting our lead story during the next live edition of Monitor Mondays will be Marcy Andersen, director of account management at SAI360.

Other segments to be featured during the live broadcast include the following:

  • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the RAs.
  • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  • Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
  • SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.