The mission of the Recovery Audit Program is to detect and correct past improper payments made on health care claims for services provided to Medicare beneficiaries. The goal is to help CMS and the MACs implement actions that will prevent future improper payments.
Recovery Auditors review claims on a postpayment basis using the same Medicare policies as MACs:
To ensure accuracy, Recovery Auditors are required to employ nurses, therapists, certified coders and a contractor medical director.
Recovery Auditors use two review processes:
To minimize provider burden, Recovery Auditors may look back only three years from the date the claim was paid; however, Recovery Auditors are unable to review claims paid prior to 10/1/2007.
| Recovery Auditor | States Serviced |
|---|---|
| Region 1: Performant Recovery, Inc. | CT, IN, KY, MA, MD, ME, MI, NH, NY, OH, RI, VT |
| Region 2: Cotiviti, LLC. |
AR, CO, IA, IL, KS, LA, MO, MN, MS, NE, NM, OK, TX, WI |
| Region 3: Cotiviti, LLC. |
AL, FL, GA, NC, SC, TN, VA, WV, Puerto Rico and U.S. Virgin Islands |
| Region 4: HMS Federal Solutions |
AK, AZ, CA, DE, HI, ID, MD, MT, ND, NJ, NV, OR, PA, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas |
| Region 5: Performant Recovery, Inc. | Nationwide for DMEPOS/HHA/Hospice |
When a Recovery Auditor finds that improper payments have been made, they will submit claim adjustments to your MAC. The MAC will perform the adjustments based on the Recovery Auditor’s review, and issue an automated demand letter to the provider. If you agree with the Recovery Auditor's determination, National Government Services will issue the recoupment offset on your remittance advice (unless you have submitted a check or a valid appeal). Recovery Auditor recoupment offsets will be identified on your remittance advice with the following ANSI remark code and message:
N432: Adjustment based on recovery audit
If you agree with the Recovery Auditor’s determination you can:
If you do not agree with the Recovery Auditor's determination you may use the Medicare appeals process. Note that you must file an appeal within 120 days of the Recovery Auditor's determination.
