Expect more aggressive audits

Monday, December 1, 2014

ATLANTA – Medicare has gone from pay-and-chase to not letting the money out, says healthcare attorney Denise Leard.

The result is more—and meaner—audits, she said during a session at Medtrade in October.

Everything starts with the CERTs, she said. It’s their job to ensure Medicare is paying claims appropriately.

“If they see a trend, then all of a sudden the ZPICs are looking,” said Leard, who works for Brown & Fortunato. “It’s very important to do a good job of responding to those.”

The biggest problem? The physician medical records.

“It’s important to get them prior to dispensing the equipment,” she said. “Now, with the face-to-face rule, you have to have that documentation in hand.”

Also topping Leard’s list of concerns is the ZPICs.

“They are the contractors I worry about the most,” she said. “They are looking for fraud and abuse, they can make referrals to law enforcement. There are increased payment suspensions out there. They’ll let you keep billing but not pay you.”

They will eventually get more aggressive she warned.

“They are looking for ways to get people out of the Medicare system,” said Leard. “They will send the National Suppliers Clearinghouse. They’ve increased unannounced inspections. They can pop in if they happen to be in the neighborhood.”

Some of this scrutiny is due to provisions in the Affordable Care Act, which also gives payers more authority in matters of screening providers.

“Fingerprinting is coming,” she said. 

And if you discover an overpayment, be prepared to pay it back fast. HME