(December 22, 2015): The number of durable medical equipment (DME) audits conducted by Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) have surged in recent years. Medicare contractors have gradually increased their scrutiny of DME suppliers’ claims.
Full Answer
What are the Medicare audit programs?
Generally, here are some of the audit programs in place: The RAC audits were developed in accordance with the Medicare Modernization Act of 2003. The program reclaims money by reviewing fee-for-service (FFA) claims – a process that has come to be known as a “clawback.” The RAC audits essentially divide the country into four regions.
Where does the Medicare audit take place?
You will often find that the Medicare audit and the site visit will occur at the branch office that appears on the claim form that you submit to the CMS. If a visit is to be scheduled at one of the offices in your practice, you want to ensure that the office is fully staffed and operational when the auditors get there.
What are the Medicare documentation billing guidelines for DME providers?
For CMS to ensure their programs operate effectively, DME providers must meet the Medicare DME documentation requirements to secure payments. Below are the Medicare documentation billing guidelines to aid the billing process. All suppliers should have documentation on file that proves medical necessity.
Do I need a lawyer for a Medicare audit?
You have the right for an attorney to be present during the Medicare audit. This is especially true if it’s the RAC audit, as it’s usually the most common—and potentially the most damaging. Get in touch with your attorney and ensure that he or she is there.
Who performs Medicare audits?
In the case of physician practices, audits are usually performed by Part B carriers. One of the more common methods used by Medicare to determine that an audit is appropriate is through the identification of billing patterns.
What are CMS audits?
These program audits measure a Sponsoring organization's compliance with the terms of its contract with CMS, in particular, the requirements associated with access to medical services, drugs, and other enrollee protections required by Medicare.
What are the two types of Medicare audits?
Types of Medicare AuditsRecovery Audit Contractor (RAC) Audits.The Certified Error Rate Testing (CERT) Audits.Probe Audits.Check the address on the letter and ensure that it is the address of your practice.Make contact with the auditors.Keep copies of all transmitted documents to the auditors.More items...
What are TPE audits?
Targeted probe and educate (TPE) audits are the latest type of audits facing Medicare providers and suppliers. TPE audits are unique in that, unlike other Medicare audits, providers and suppliers may be subject to up to three rounds of record reviews.
What are the 3 types of audits?
Key Takeaways. There are three main types of audits: external audits, internal audits, and Internal Revenue Service (IRS) audits. External audits are commonly performed by Certified Public Accounting (CPA) firms and result in an auditor's opinion which is included in the audit report.
What are the 4 types of audit reports?
The four types of audit reportsClean report. A clean report expresses an auditor's "unqualified opinion," which means the auditor did not find any issues with a company's financial records. ... Qualified report. ... Disclaimer report. ... Adverse opinion report.
What is the difference between Mac and RAC?
MAC audits are powerful and intrusive procedures that have the potential to lead to serious federal charges for healthcare entities. A Recovery Audit Contractor (“RAC”) reviews claims and identifies overpayments from Medicare so that CMS and other auditors are able to prevent improper payments in the future.
What is a RAC audit in Medicare?
What does a Recovery Audit Contractor (RAC) do? RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.
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.
What is a CMS TPE?
CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. The goal: to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them.
What triggers Medicare audits?
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 triggers a RAC audit?
RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare's clinical payment criteria, documentation and billing requirements.
When will CMS reprocess claims?
Claims for these accessories submitted prior to July 1, 2020, with dates of service from January 1, 2020 through June 30, 2020, will need to be reprocessed to ensure that CMS pays the unadjusted fee schedule amounts, as required by section 106 of the Further Consolidated Appropriations Act, 2020.
What is gap filling in Medicare?
For newly covered items of DMEPOS paid on a fee schedule basis where a Medicare fee does not exist , the Centers for Medicare & Medicaid Services (CMS) uses a process to establish fees called gap-filling. This allows Medicare to establish a price that aligns with the statutory requirements for the DMEPOS fee schedule.
What is Medicare Accessibility Act?
CMS is implementing the Patient Access and Medicare Protection Act to ensure that beneficiaries have access to wheelchair accessories and seat and back cushions when furnished with Group 3 complex rehabilitative power wheelchairs. To ensure beneficiary access to these accessories particularly for these vulnerable populations, advance payment may be available for suppliers. Prior to July 1, suppliers will be paid the adjusted fee schedule rates. The average reduction during this period for these items is approximately 10%. During this time, CMS has announced that suppliers are able to submit a single advance payment request for multiple claims if the conditions described in CMS regulations at 42 CFR Section 421.214 are met. Additional information is below.
What is a DMEPOS file?
The DMEPOS public use file contains fee schedules for certain items that were adjusted based on information from the DMEPOS Competitive Bidding Program in accordance with Section 1834 (a) (1) (F) of the Act.
What is TTFT in Medicare?
TTFT is a system consisting of an electromagnetic field generator and transducer arrays and will be covered under the Medicare Part B benefit for durable medical equipment (DME) for items and services furnished on or after September 1, 2019.
When will Medicare change the KU modifier?
As aforementioned, these system changes will be implemented on July 1, 2020.
What is a CGM?
CGMs are items of durable medical equipment (DME) that provide critical information on blood glucose levels to help patients with diabetes manage their disease . In January 2017, CMS issued a ruling providing for Medicare coverage of therapeutic CGMs.
How old is a DME claim?
The nature of postpayment auditing is that the claims can be quite old, sometimes as old as four years (or even longer if fraud or similar fault is suspected!). If a DME supplier has not been vigilant about collecting medical records, this could pose a real problem. There are two major issues that DME suppliers face in this regard: (1) physicians are unwilling or cannot produce the medical documentation when it is requested after so much time has passed; and (2) physicians do produce the medical documentation requested but the documentation blatantly does not support the medical need for the DME item that was supplied. In regard to the latter, an example of this type of situation is where a patient has been prescribed a back brace for low back pain or lumbago but the medical record associated with the date of the order does not discuss back pain or back-related issues and does not even reference the order for the back brace. Believe it or not, we have seen this type of situation over and over again. In either scenario, there is nothing the DME supplier can really do to rectify the missing or deficient medical records. The DME supplier, and not the physician, is then stuck with the liability if a Medicare contractor audits your DME claims and determines the claims are non-covered.
What is the OIG work plan for 2016?
The United States Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Fiscal Year 2016 Work Plan. This annual publication identifies new and ongoing investigative, enforcement, and compliance activities HHS-OIG has decided to allocate resources to. For 2016, HHS-OIG has added the review of Medicare Part B payments for orthotic braces to its agenda. Specifically, HHS-OIG intends to determine whether DME suppliers’ claims were medically necessary and were supported in accordance with Medicare requirements because prior OIG work indicated that some suppliers were billing for items that were medically unnecessary “ or were not documented in accordance with Medicare requirements .” (emphasis supplied). There are also ongoing agenda items pertaining to power mobility devices and nebulizer machines (and related drugs) to ensure supplier compliance with Medicare requirements. Based on the Work Plan, DME suppliers should expect that postpayment medical review audits will continue, if not increase, this coming fiscal year.
Is DME auditing required in 2016?
DME audits in 2016 aren’t mere speculation — they are a certainty. Fortunately, even though this requirement is burdensome, there are steps DME suppliers can take to mitigate their risk. These include,
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 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.
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.
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.
How did the DME scam work?
According to allegations in 2019 court documents, defendants in a $1.2 billion DME scam lured patients through an international call center that targeted Medicare beneficiaries. The telemarketers “up-sold” the beneficiaries to get them to accept numerous “free or low-cost” DME braces, regardless of medical necessity. The call center allegedly paid illegal kickbacks and bribes to telemedicine companies, doctors, or nurse practitioners, to obtain DME orders for these Medicare beneficiaries without ever speaking to them. Finally, they sold the orders to DME companies, who shipped out box after box of braces. The DME suppliers fraudulently billed Medicare or other insurance programs for every item.
What did the call center do to Medicare?
The call center allegedly paid illegal kickbacks and bribes to telemedicine companies, doctors, or nurse practitioners, to obtain DME orders for these Medicare beneficiaries without ever speaking to them. Finally, they sold the orders to DME companies, who shipped out box after box of braces.
What is the purpose of the Integrity Agreement?
The Integrity Agreement promotes compliance with the statutes, regulations, program requirements, and written directives of Medicare and all other federal healthcare programs. Among other compliance obligations, the Integrity Agreement requires that SPI must establish and maintain a compliance program.
What is the OIG?
In a time where regulatory enforcement might easily lose the spotlight, the Office of the Inspector General (OIG) has shown that combating fraud and penalizing Medicare non-compliance remain priorities.
Is the government losing focus on fraud?
Despite the overwhelming but necessary emphasis on public health and COVID-19 protections, the government has not lost focus on its central healthcare delivery programs and their susceptibility to fraud. In a time where regulatory enforcement might easily lose the spotlight, the Office of the Inspector General (OIG) has shown that combating fraud and penalizing Medicare non-compliance remain priorities.