In order to understand Medicare audits of physi-cian practices, a few words about the Medicarecmsreimbursement system are in order.The con-tracts with insurance companies to review claims,to pay claims,and to investigate and respond toallegations of fraud and abuse.These insurancecompanies are commonly referred to as intermedi-ariesfor Part A claims and carriers for Part Bclaims.In the case of physician practices,auditsare usually performed by Part B carriers. One ofthe more common methods used by Medicare todetermine that an audit is appropriate is throughthe identiWcation of billing patterns.Because claiminformation is stored electronically, Part B carriers’analysts, auditors, and investigators can quicklyidentify physicians whose billing patterns for aparticular procedure or procedures exceed thenorm set by their peers.Carriers often elect toaudit these “aberrant”billing patterns and “out-lier”physicians.
Full Answer
What is a Medicare fraud?
A provider that charges Medicare twice for a service or item that you only got once. A person who steals your Medicare number or card and uses it to submit fraudulent claims in your name. A company that offers you a Medicare drug plan that Medicare hasn’t approved.
What should you do if you are subject to Medicare audit?
If you are subject to a Medicare audit, make sure to do your due diligence in research before selecting an attorney. Your business is at risk, so it is crucial that your representation has experience and a history of success in this field.
How do Medicare Audit Contractors review audiologists and speech pathologists?
As policymakers consider legislative and regulatory action to curb fraud, waste, and abuse, claims and services by audiologists and speech-language pathologists are subject to review by one or several audit contractors. There are several types of Medicare contractors with the responsibility of auditing records, claims, and payments.
Who investigates Medicaid fraud?
However, for the most part, Medicaid fraud allegations will be investigated by state law enforcement officials. All states have a state medicaid fraud control unit (MFCU) or similar agency, usually operating under the authority of the state's attorney general or its Medicaid agency.
How does Medicare detect fraud?
Detect fraud by examining both the Medicare Summary Notice (MSN) you receive from Medicare after your claims are paid, and/or the Explanation of Benefits (EOB) you receive from your Part C and/or Part D plan. (You can also view your MSNs online by accessing your Medicare account at Medicare.gov.)
What can trigger a Medicare audit?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What happens when Medicare audits you?
Failure to comply with CMS requirements or cooperate during an audit could result in the provider being excluded from providing services through Medicare or Medicaid.
What factors are red flags for Medicare fraud?
Some red flags to watch out for include providers that:Offer services “for free” in exchange for your Medicare card number or offer “free” consultations for Medicare patients.Pressure you into buying higher-priced services.Charge Medicare for services or equipment you have not received or aren't entitled to.More items...
What does Medicare look for in an audit?
According to the CMS website, CERT audits are conducted annually using “a statistically valid random sample of claims.” Auditors review the selected claims to determine whether they “were paid properly under Medicare coverage, coding, and billing rules.”
Are Medicare audits random?
For example, the Medicare program is required to make random audits of 10% of all Medicare providers on an ongoing basis. An audit or investigation can result from complaints by patients about the quality or appropriateness of the care they received, or how they were billed for their care.
How long does a Medicare audit take?
After the provider is “targeted” using data analytics, the MAC performs up to three rounds of "probe and Educate." Each round takes about 90 days—30 days for MAC to review the claims, a few days to schedule an educational call, 45 days for providers to show improvement—and is centered around a one-on-one educational ...
What are the types of Medicare audits?
There are mainly three types of audits — Recovery Audit Contractor (RAC) audits, Certified Error Rate Testing (CERT) audits and Probe audits. Mistakes in medical documentation, coding and billing can rouse Medicare's suspicion during audits, which can lead to claim denials.
How far back does a Medicare audit go?
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.
What are the five areas covered in the Red Flags Rule?
In addition, we considered Red Flags from the following five categories (and the 26 numbered examples under them) from Supplement A to Appendix A of the FTC's Red Flags Rule, as they fit our situation: 1) alerts, notifications or warnings from a credit reporting agency; 2) suspicious documents; 3) suspicious personal ...
What is the red flag rule in healthcare?
The Red Flags Rule requires that organizations have “reasonable policies and procedures in place” to identify, detect and respond to identity theft “red flags.” The definition of “reasonable” will depend on your practice's specific circumstances or specific experience with medical identity theft as well as the degree ...
How do banks know red flags?
Photograph on ID inconsistent with appearance of customer. Information on ID inconsistent with information provided by person opening account. Information on ID, such as signature, inconsistent with information on file at financial institution. Application appearing forged or altered or destroyed and reassembled.
What do Medicare auditors take?
Auditors will most likely take pictures of several things – including photographs, diplomas, letters , awards, and licenses. Ensure that none of these are expired – or worse, false. For Medicare pharmacy audits, the auditors might also inspect cabinets and drawers to snap what’s inside them.
What was the Obama administration's goal in 2010?
In 2010, the Barack Obama administration launched an initiative that sought to reduce the amount of money spent on subpar Medicare payments. Since the initiative, there have been more efforts to reduce payment errors. Generally, here are some of the audit programs in place:
What to do if you are subject to Medicare audit?
If you are subject to a Medicare audit, make sure to do your due diligence in research before selecting an attorney. Your business is at risk, so it is crucial that your representation has experience and a history of success in this field.
What is CERT audit?
CERT audits are primarily conducted using a “statistically valid random sample of claims.” The auditor will essentially review a specific number of claims to determine whether they are appropriately paid under all applying rules.
Should you brush up on intelligence questions before an auditor visit?
You should brush up on answers to questions that you may be asked before the auditors visit. However, remember that this isn’t an intelligence test. Your employees will need to answer questions truthfully.
Do auditors want a private room?
The auditors will most likely want a private, separate room that they can use and have their meetings in. Ensure that the room is clean and that fixtures are in top shape. Remember that the auditors might want to conduct interviews with all employees.
How long does it take to get a QIC reconsideration?
If the provider disagrees with the redetermination results, the provider may request in writing, within 180 days, a reconsideration performed by a QIC. A copy of the RA and any other useful documentation should be sent with the reconsideration request. The QIC reconsideration process includes an independent review of the determination and redetermination and may include review by a panel of physicians or other related health care professionals. A minimum monetary threshold is not required to request reconsideration. Reconsideration request forms are available on the Medicare administrative contractors' websites.
What is Medicare audit?
There are several types of Medicare contractors with the responsibility of auditing records, claims, and payments . Each type of contractor may use different methods to conduct audits, but they must all abide by overarching Medicare guidelines for medical review, denials, appeals, and payment recovery, as set forth by the Centers for Medicare and Medicaid Services (CMS).
What is a partial denial?
A full denial or partial denial can be issued. For a partial denial, the auditor determines that the submitted services was up-coded (a lower service was actually performed) or incorrectly coded.
How long does it take to get a judicial review?
If a minimum amount (determined annually-for example, the 2021 minimum amount is $1,760) or more is still in controversy following the Appeals Council's decision, the provider can request a judicial review within 60 days. The Appeals Council's decision letter contains the instructions regarding the judicial review request.
What is postpayment review?
Postpayment review may result in no change to the initial payment to the provider or may result in a "revised determination" that would require the provider to pay back monies for services determined to be "not reasonable or necessary.".
When is an appeal appropriate?
Appeals are appropriate when a claim has been reviewed for "reasonable and necessary" services and the provider disagrees with the final determination or has additional documentation that can further establish that reasonable and necessary services were provided.
Is an item or service considered necessary?
The item or service is statutorily excluded. The item or service is not reasonable and necessary. The item or service does not meet other Medicare program requirements for payment. Auditors must adhere to CMS issued national coverage determinations (NCDs) and regional local coverage determinations (LCDs).
What is TPE data analytics?
TPE uses data analytics to target only those physicians who have high denial rates or unusual billing practices. Additionally, the focus of TPE is on educating physicians about billing errors rather than recovering payments.
How long can RACs go back?
CMS shortened the timeframe a RAC can go back and recover monies from 4 years to 3. RACs must have certified coders. RACs can request up to 10 medical records per single practitioner within a 45-day period, but current advocacy seeks to lower the amount to no more than 3 within a 45-day period.
Why is an independent external validation process mandatory?
An independent external validation process is now mandatory to help ensure audit areas are appropriate. RACs must offer physicians the chance to discuss improper payment identification with the contractor medical director. Go to an interactive map for information about your RAC contractor.
What is TPE in Medicare?
The Centers for Medicare and Medicaid Services (CMS) established the Targeted Probe and Educate (TPE) process in response to physicians concerns about how the Medicare Administrative Contractors (MAC) selected claims for review. TPE uses data analytics to target only those physicians who have high denial rates or unusual billing practices.
How long do CMS review topics last?
Proposed review topics are posted on the CMS website for 30 days prior to approval so that physician groups can weigh-in. RACs will not receive contingency fees until after the second level of appeal and contingency fees must be paid back if the RACs ultimately lose on appeal.
Why was the RAC program created?
Congress created the RAC program to help identify improper Medicare payments. RAC auditors are private contractors paid a commission by the government to: Identify overpayments or under payments. Recoup overpayments or return underpayments.
Why is the AMA important?
The AMA works to ensure that the federal government’s program integrity policies are equitable. Read AMA letters to learn more about the depth of involvement into the issues ...
What forms should be included in a nursing home discharge?
Consent forms, medical history questionnaires, histories, physicals, other physicians' orders, all may be a crucial part of the record and should be included. If hospital or nursing home discharge orders or other orders referred the patient to you, obtain these to provide to the auditors.
Do auditors ask for medical records?
In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.
Should Medicare contractor be taken seriously?
All correspondence from Medicare, or the Medicare contractor, should be taken seriously. Avoid the temptation to consider the request from Medicare, or the Medicare contractor, just another medical records request. Avoid the temptation to delegate this as a routine matter to an administrative employee.
Is Medicare a routine audit?
Although you may speak of a "routine" Medicare audit, there is really no such creature. This is like saying you have a "routine IRS audit." The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.
Is a summary a substitute for medical records?
The summary is not a substitute for the medical records, but will assist an auditor that may not be experienced in a particular specialty or practice area. Make sure that any such summaries are clearly marked as summaries with the current date they are actually prepared. Label it accurately.
Can you alter a medical record after an audit?
Never alter the medical records after a notice of an audit. However, if there are consults, orders, test reports, prescriptions, etc., that have not been filed into the chart, yet, have these filed into it, as you normally would, so that the record is complete.
What is RAC in Medicare?
Developed as part of the Medicare Modernization Act of 2003, the RAC program reclaims money by conducting retrospective reviews of fee-for-service (FFS) claims—a process known as “claw back.”. For this initiative, the country is divided into four regions.
What do you need to know about Medicare audits?
1. There are three major audit-worthy red flags for physical therapists. As you know, Medicare policy is a web of super-confusing rules and regulations.
What happens if you fail to comply with a federal investigation?
If you fail to comply, you will not receive reimbursement for the claim.
Types of audits
Healthcare providers may be subject to different types of audits, each requiring different approaches. Private commercial payers may conduct informal reviews of a few claims or seek formal review of many claims.
California Healthcare Audit Lawyers
For help with payer audits and other healthcare business matters in Los Angeles and California statewide, call the Law Offices of Art Kalantar in Beverly Hills at 310-773-0001 for a free initial consultation.
