Industry works to respond to audit overload

Thursday, August 19, 2010

WASHINGTON - AAHomecare's audit task force will meet this week to craft a strategy for dealing with an onslaught of audits that have hammered the industry in recent months.

"We are going to wade into this issue and seek relief for providers," said Walt Gorski, the association's vice president of government affairs.

The task force was formed in June to develop guidelines for Medicare auditing policies.

"We are finding a number of problems with the auditing criteria used by Medicare's contractors," said Gorski. "We want clear, consistent and reasonable standards by which claims are reviewed."

Stakeholders and providers have decried the audits--being conducted by the DME MACs, ZPIC, OIG, CERT and RAC--as being overly aggressive and burdensome. In many cases, they say, the auditors aren't playing fair.

"There is a complete lack of transparency and there is no oversight," said Sylvia Toscano, owner of Boca Raton, Fla.-based billing firm Professional Medical Administrators. "The ZPIC doesn't operate in conjunction with the program integrity manual."

AAHomecare is asking providers for examples of auditors requesting documentation that is not required to justify a claim. The task force will categorize the problems by audit type and product type and then plans to start meeting with policymakers to discuss solutions, Gorski said.

Of course, audits are nothing new, but healthcare reform and a presidential mandate that calls for reducing improper payments by 50% have upped the stakes.

"One of the cornerstones of the healthcare reform bill is that one of the key ways it will pay for itself is through reducing waste, mistakes and fraud," said attorney Neil Caesar, president of the Health Law Center. "The shortsighted idea is that there is a substantial and unending supply of waste for them to tap into."

It doesn't help that auditors get paid to find mistakes, he added.

"What I am noticing from these contracted bounty hunting agents is a more aggressive approach," said Caesar. "They are seeing what and how much they can get and away with before they get slapped down for it."

While audits are happening across the country, states like Florida and Texas, which have had higher rates of fraud and abuse, have been especially hard hit.

"I get calls from providers every day who are closing," said Sean Schwinghammer, executive director of the Florida Alliance of Home Care Services. "In many cases, once an audit begins, providers are no longer paid for that item and oftentimes its one of their biggest items."

Schwinghammer is quick to add that it's not just the cash-flow interruption driving providers to call it quits. It's also the relentlessness of the audits.

"There are no time limits on the audits, providers don't know how long it will take," he said. "They get one file and they come back and ask for another file. And it keeps going. You can get cleared and then they ask for more. There is no end."