Audits: Too much of a bad thing

‘Many providers are still trying to get back on their feet’
Friday, August 3, 2012

YARMOUTH, Maine – Some home medical equipment providers are learning that any relief they get from being released from a prepay review can be short-lived.

Industry stakeholders report that some providers released from a prepay review are being put back on a prepay review as little as a few months later.

“It used to be that I would tell providers, ‘Once you get through this, you’ll be in good shape and you’ll have the green light,’” said Kelly Wolfe, CEO of Regency Billing and Consulting. “Not anymore.”

Another scenario, according to stakeholders: Providers released from a prepay review are getting hit with a post-pay review even before the results of the prepay review are known.

Stakeholders have a few theories as to what’s going on. The most common: That the spike in billing that often occurs after a provider is released from a prepay review raises red flags again.

“Your inclination is to blast out everything that has been stockpiling for the past three months or six months,” said Sylvia Toscano, owner of Professional Medical Administrators. “But you have to send in the claims incrementally.”

Other theories: That the contractors are targeting a certain doctor and, therefore, any provider he’s referring to is getting audited repeatedly; or that investigators working for the same contractor aren’t talking to each other about previous audits, resulting in recycled cases.

“We’ve found that the investigators aren’t always aware, which is kind of scary,” said Wayne van Halem, president of The van Halem Group. “In one case, we were able to inform an investigator of a previous audit and they cancelled the new audit.”

Sometimes, it’s as simple as this, stakeholders say: Contractors want to check up on providers.

“They want to know, ‘Are you still doing a good job now that we’ve let you off the hook,’” said Andrea Stark, a reimbursement consultant with MiraVista. “They reserve the right to come back in.”

Contractors may have the right to come back in, but that’s of little comfort for providers trying to negotiate back-to-back prepay reviews.

“Many of these providers are still trying to get back on their feet after surviving the first one,” van Halem said.


Read below and you will see that CMS is preparing to do Provider Profiling.


Medicare fraud busters unveil command center


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Aug 1, 12:27 PM (ET)




(AP) In this Feb. 14, 2012 file photo, Health and Human Services (HHS) Secretary, Kathleen...
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BALTIMORE (AP) - Medicare's war on fraud is going high-tech with the opening of a $3.6 million command center that features a giant screen and the latest computer and communications gear. That's raising expectations, as well as some misgivings.

The carpeting stills smells new at the facility, which went live a week ago in a nondescript commercial office park on Baltimore's outskirts. A couple dozen computer workstations are arrayed in concentric semicircles in front of a giant screen that can display data and photos, and also enable face-to-face communication with investigators around the country.

Medicare fraud is estimated to cost more than $60 billion annually, and for years the government has been losing a game of "pay and chase," trying to recoup losses after scam artists have already cashed in.

Fraud czar Peter Budetti told reporters on a tour this week that the command center could be a turning point. It brings together in real time the geeks running Medicare's new computerized fraud detection system with gumshoes deployed around the country. Imagine a kind of NCIS-Medicare, except Budetti says it's not make-believe.


"This is not an ivory-tower exercise," Budetti said. "It is very much a real-world one."

But two Republican senators say they already smell boondoggle.

Utah's Orrin Hatch and Oklahoma's Tom Coburn say Medicare's new computerized fraud detection system, a $77-million investment that went into operation last year, is not working all that well. In a letter to HHS Secretary Kathleen Sebelius, they questioned spending millions more on a command center, at least until the bugs get worked out.

"Institutionalizing relationships through establishing a (command) center may be useful, but if huge sums of money have indeed been spent on a video screen while other common-sense recommendations may have not been implemented due to 'resource concerns,' this seems to be a case of misplaced priorities," wrote Hatch and Coburn. Insiders are telling them the screen alone cost several hundred thousand dollars, the senators say.

The two Republicans may have more than congressional oversight in mind. In an election year, Medicare fraud is an issue with older voters because it speaks to the Obama administration's stewardship of the program.

Responded Budetti: "Our expectation is that this center will pay for itself many times over."

Conducting what amounted to her first formal inspection on Tuesday, HHS Secretary Sebelius set the bar high for the command center, nothing less than the end of "pay and chase."

"Preventing fraud and abuse is what this effort is about," she said.

The government's new antifraud computer system aims to adapt tools used by credit card companies to stop theft from Medicare and Medicaid. It was launched with great fanfare last summer. But by Christmas, it had stopped just one suspicious payment from going out, for $7,591. Administration officials say that shouldn't be the only yardstick, and the system has made other valuable contributions.

Sebelius spoke with three groups of staffers during her visit Tuesday. One group was responsible for developing computer models to query billing data for suspicious patterns; another in charge of investigating data generated by the computer models, looking for mistakes as well as real fraud; and a third handling coordination with law enforcement around the country. The staffers said they expect the coordination to cut the time it takes to investigate suspected fraud schemes from months to days and weeks.

Hatch's office says development of the computer models has lagged. Command center staffers told Sebelius the first-year goal is to have 40 such computerized anti-fraud queries to sift through millions of incoming claims.

The administration must report to Congress on the antifraud computer system later this year, an assessment that will first be independently reviewed by the Health and Human Services inspector general's office.

Hatch and Coburn say they have repeatedly pushed the administration for details and "the responses have been polite, but vague."

Medicare scams have grown into sophisticated networks where crooks file millions of dollars in bogus claims and take off with the money. Sometimes they even manage to flee abroad to countries where the feds can't touch them.