Could recoupments be unconstitutional? Case law is changing in favor of healthcare providers who accept Medicare and/or Medicaid. Without question, accepting Medicare and/or Medicaid payments creates a legal risk of regulatory audits. Because the reimbursements constitute tax dollars, the federal and state governments (sometimes via a contracted entity) have the…
Effective Jan. 2, 2019, the Centers for Medicare & Medicaid Services (CMS) radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC). Extrapolation is a veritable tsunami in…
Although the details of federally ordered auditing of providers have changed over the years, one thing remains the same. We have lived for years under the Sword of Damocles – the continuing waves of healthcare audits by federal contractors. The names of the Medicare Recovery Audit Contractors (RACs) have changed…
“Urgent” memo marks obvious disagreement among contractors. In what can only be described as highly unusual, a Medicare Administrative Contractor (MAC) has advised home health providers who have had claims audited and denied by the Comprehensive Error Rate Testing (CERT) contractor to appeal those denials. The announcement was made today…
Latest move by CMS raises more questions. CGS, a Medicare Administrative Contractor (MAC), on Thursday released an email notice indicating that the Centers for Medicare & Medicaid Services (CMS) has instructed it to stop seeking recoupment or issuing demand letters for Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) Hospital…
100% error rate audits challenge credibility. Over the past five or six years, I have worked as a statistical expert on hundreds of extrapolation audits. And at least a couple dozen of these were based on 100 percent error rates. That means that the auditor determined that, of all of…
TPE audits appear to be on the rise. The old baseball adage, “three strikes and you’re out,” now has relevance in the Medicare audit arena. 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…
Error reported by WPS/GHA  might have nationwide ramifications. Medicare Administrative Contractor (MAC) WPS GHA today confirmed that an enhancement to its Fiscal Intermediary Shared System (FISS) caused erroneous additional documentation request (ADR) letters to be sent to providers. In a posting to its website, WPS GHA reported that the error…
The scoring mechanisms of the MDM are suggested tools, not rules or laws. In our last article we explored how time in conjunction with medical decision-making (MDM) must support the same level of service, and why that rule makes sense. However, we were left with a puzzling consideration in regard…
Providers must document the complexity of care for each and every patient. There is a standard misunderstanding of the utilization of time-based documentation and billing. Clearly, over time, many opinions and interpretations of ambiguous guidelines have clouded this topic, and it is time that we get back to the basics…
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