Different payer, different rules, different audit

Tuesday, January 22, 2013

Medicaid doesn’t always follow Medicare, and therein lies the rub for HME providers doing battle in this latest frontier on audits, industry consultants say.

Case in point: For diabetes supplies, Medicare requires a new order when there is a change in the order, but Medicaid requires a new order every year, says Wayne van Halem, president of The van Halem Group in Atlanta.

“We had a client who went through a Medicaid audit for diabetes supplies and because they didn’t have a new order for a new year, they had to refund some money,” he said.

While Medicaid audits are still relatively few and far between compared to Medicare audits, consultants say it’s only a matter of time before they become just as chronic.

That’s why providers want to be “100% familiar” with Medicaid guidelines, particularly as they relate to what documentation they need to submit and when, says Sylvia Toscano, owner of Professional Medical Administrators in Boca Raton, Fla.

“We bill Medicaid in 17 states, and we don’t find that Medicaid follows Medicare guidelines in most cases,” she said. “It’s important that providers don’t just apply one set of standards, regardless of payer type.”

Providers should also take note that, in most states, when an auditor identifies a Medicaid overpayment, it’s less of an administrative process and more of a legal process, van Halem says.

“They turn it over to attorneys and there are hearings,” he said. “There’s a draft report that you can respond to and then there is a final report that’s turned over to the state attorney that you can appeal.”

The good news, van Halem says: “We’ve been able to negotiate a little bit if the provider agrees, for example, to pay the money back right away.”

The bad news, says Kelly Wolfe, CEO of Regency Billing and Consulting in Largo, Fla.: Because Medicaid reimbursement is only a percentage of Medicare reimbursement, “providers are having to work twice as hard for even less money.”

[See also: GAO labels Medicaid auditing process ‘inefficient’]

[See also: ‘Rubber stamp’ approach leads to denials for diabetes claims]

[See also: In this case, let us root the GAO on]