Skip to Content

New audit program makes concessions

New audit program makes concessions Puts emphasis on education, rewards improved performance

WASHINGTON - HME stakeholders and billing consultants are “cautiously optimistic” about a new program aimed at streamlining the number of audits.

CMS announced Aug. 14 that the Medicare Administrative Contractors will soon start focusing their reviews on providers that have the highest claim error rates or irregular billing practices, eliminating the burden on providers who are already submitting claims that are compliant.

“We're cautiously optimistic, but it's something we'll be monitoring,” said Kim Brummett, vice president of regulatory affairs for AAHomecare.

Sometime this year, as part of expanding its “Targeted Probe and Educate” program, the MACs will turn off service-specific reviews and turn on these provider-specific reviews across all jurisdictions.

A big reason for the optimism surrounding the program: After each of up to three rounds of probes of 20 to 40 claims per provider, the MACs will offer individualized education to targeted providers based on the results of their reviews.

“I'm excited about that,” said Mary Stoner, president of Electronic Billing Services in Sikeston, Mo. “That gives an opportunity for these providers to really get in there and learn what went wrong.”

The pause between probes for education also gives targeted providers a breather from audits.

“In the past, once providers got bad results, the audits were constant,” said Kelly Wolfe, owner of Regency, Inc. in Largo, Fla.

Stakeholders and consultants hope the education also serves as a discussion period of sorts, allowing reviewers and targeted providers to work out issues with claims, some of which could benefit from clinical inference.

“They may say the physician didn't document why the patient couldn't use a cane or walker, but the physician did write that the patient had bilateral wounds on their feet and was non-weight bearing,” Brummett said. “There's this mentality that if you educate suppliers to do it right, life will be good, but the biggest fear is the nurse reviewer and an incorrect review.”

Another reason stakeholders and consultants are optimistic: Targeted providers may be removed from reviews after any of the three rounds of probes if they demonstrate low or improved error rates.

“Providers can prove themselves and close out these probes,” Stoner said. “They can stop.”

Still, there are a number of vagaries about the program that concern stakeholders and consultants. While CMS says the MACs will target providers using data analysis, it doesn't say what will be considered a high error rate.

“They're not publishing that,” Brummett said. “I get why—if they say it's 50%, that looks like a ridiculously high number, especially on the Hill—but we're hoping the MACs are going to be reasonable.”

Additionally, stakeholders and consultants remind providers the stakes are still high under the new program. Providers with continued high error rates after three rounds of review may be referred to CMS for additional action.

“CMS has made comments that they could be turned over to CMS, the RAC or to the ZPICs,” Brummett said. “The ZPIC is a bit terrifying. They have broad authority; they could kill a provider's supplier number.”


To comment on this post, please log in to your account or set up an account now.