Expert advice: Fight audits tooth-and-nail

Monday, April 30, 2007

Providers have "legitimate concerns" about CMS's Recovery Audit Contractor (RAC) demonstration, say industry attorneys. For that reason, they encourage providers to fight the audits tooth-and-nail.
"My sense is that it would be a huge process but a worthwhile one in a lot of cases," said Asela Cuervo, a Washington, D.C.-based industry attorney. "There's material for appeals."
Added industry attorney Elizabeth Hogue: "Providers should really be prepared to go to the wall with some of the findings they receive. It's going to take the kind of persistence and resources I don't even like to think about, but they should do it."
Here's what else the attorneys had to say:
Who are they to judge?
Cuervo and Hogue both questioned whether the RACs are qualified to conduct the audits. "Do they have a familiarity with HME billing?" asked Hogue, a healthcare attorney based in Burtonville, Md. "They're going to say they do, but I have my doubts."
A few alternatives
When it comes to paying the RACs, it might have been more fair for CMS to consider, say, a flat fee per audit plus expenses or a sliding scale, said industry attorney Jeff Baird. "Is (the financial arrangement) a conflict of interest legally--no," he said. "Is it ethically--perhaps."
Human nature
"Every business out there, whether it's a shoe store or my personal checkbook--there are going to be some mistakes," said Baird. "That's human nature. In the past, when there were non-substantive, non-serious issues, providers got a pass." Not anymore: "When you have a company whose income is based on the recovery of money, again, it's human nature for them to do all they can to recover whatever they can," he said. "That means there's no problem small enough."
Industry attorney Neil Caesar doesn't think the government has ever been friendly, but for about a decade, now, there's been an increasingly "impersonal and disinterested" relationship between the government and providers. "(The RACs) have all the incentive to be aggressive in their interpretation," he said. "This mercenary bounty hunter approach reflects a disturbing trend."