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Prior Authorizations: Problems When in the Wrong Hands

Marcy Andersen was a featured guest on the Monitor Monday podcast to discuss Recovery Auditors and the prior authorization process.

SAI360's Marcy Andersen on Prior Authorizations with Monitor Mondays

Marcy Andersen is a director of account management at SAI360 and is an expert in healthcare regulatory and compliance topics. She spoke with Monitor Mondays on March 7, 2022.

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?

Listen to the Monitor Monday podcast. Marcy’s interview starts at 24:33.

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