Region D's Hoover on auditing

Tuesday, April 30, 2002

NASHVILLE, Tenn. — HME News talked to Region D Medical Director Dr. Robert Hoover last month regarding industry claims that the DMERCs are auditing more aggressively than ever before. In Region D, Hoover said, that is not the case. In fact, Cigna does everything it can to educate providers so they submit clean claims. "The more times you touch a claim, the less efficient you are," Hoover said. "It makes our job easier when we don't find errors." Perceptions that the DMERCs are more aggressive in their audits, is just that, a perception, at least in Region D, Hoover said. Here's what else he had to say:

HME: Do the DMERCs have any incentive for being super aggressive when it comes to provider audits?

Hoover: There is no bounty system, no metric that says we have to collect X dollars in overpayments. The only obligation we have to the government is that if we identify an overpayment that we collect it. We don't get any benefit from that overpayment collection. Nor are we docked if we did 10 provider reviews and there were no corrective actions to do.

HME: What about a recent press release from Region C, touting the fact that it saved taxpayers $663 million through various payment safeguard activities in fiscal 2001? Palmetto must hope to gain something from putting out that press release.

Hoover: I can't speculate on why Palmetto would make a statement like that. I haven't seen a similar statement from Cigna. From my perspective as medical director, we see our primary role as education. There are two ways to save money. One is with the big stick and the overpayment, and certainly there are going to be some overpayments that are assessed. But what we are seeing now, and for the past couple of years, is medical reviews role moving out of the big stick role into a more educational role.

HME: What's your mindset going into an audit?

Hoover: We go into it saying this is abnormal utilization, abnormal in the sense that there is an average and these people are outlyers. There may be a good reason why that person is an outlyer. They may have a marketing campaign or they provide excellent service to physicians they serve. That still doesn't absolve the carrier from looking at them.

HME: So at least in Region D, you are no more aggressive in your auditing of providers than you were several years ago?

Hoover: Not that I am aware of. HME