Medicare audits: 'It's not just about the outliers anymore'

Sunday, November 15, 2009

YARMOUTH, Maine - Industry stakeholders predict that an alphabet soup of Medicare audit-related activities will give HME providers even more to worry about heading into the new year.

Stakeholders point out that the Recovery Audit Contractors (RACs) have begun investigating improper payments for HME nationwide; the Comprehensive Error Rate Testing (CERT) contractor has re-doubled its efforts after being criticized for its inaccuracy; and Medicare will begin denying claims that include the name of physicians that aren't listed in its Provider Enrollment, Chain and Ownership System (PECOS).

"This could be the real sleeper issue," said John Shirvinsky, executive director of the Pennsylvania Association of Medical Equipment Suppliers (PAMS). "It may not be a big deal yet, but it's going to be."

Spurring the layer upon layer of audit-related activity, industry stakeholders say: Medicare is under pressure, like never before, to reduce waste in the system due to the lagging economy and headline-grabbing fraud and abuse scandals.

As a result, providers should have their ducks in a row, industry stakeholders say.

"When it comes to claims accountability, Medicare and its contractors are using all the language that's on the books--even things like having a legible physician signature," said Andrea Stark, a reimbursement consultant with MiraVista. "They're looking for reasons to deny claims, not reasons to pay claims. That's really the cause for concern."

In addition to being pickier, Medicare is casting a bigger net, industry stakeholders say.

"They're targeting more of the mainstream HMEs," Stark said. "It's not just about the outliers anymore."

Provider Kathy Nichols says she's aware that Medicare and its contractors are looking at HME providers with a higher-powered microscope.

"For us, it's been the status quo so far," said Nichols, vice president of operations for Cooley Medical Equipment in Prestonsburg, Ky. "But we continue to keep our files in check, and we continue to do in-house audits."