An audit crystal ball

Tuesday, September 24, 2013

HME providers often gripe that they need a crystal ball to foresee where Medicare audits might go next.

But there’s something even better than a crystal ball, says Denise Fletcher, a healthcare attorney with Brown & Fortunato: CMS leaves plenty of clues providers can use to anticipate future audits.

Fletcher will share her tips for navigating audits and the difficult appeals process at Medtrade, and offered this first glance.

HME News: What’s the audit climate like right now? 

Denise Fletcher: The right hand doesn’t seem to know what the left hand is doing. Sometimes they’ll ask for documentation on the same claim. One of my clients had an extrapolated overpayment, and the ZPIC should have put it into the RAC warehouse to prevent a RAC from looking at the claims. They didn’t do that, so my client was getting an audit from the RAC on claims he was already making payments to. It’s very frustrating.

HME: What’s one of the tips you’ll provide at Medtrade? 

Fletcher: I will talk about how to stay a recoupment. They cannot collect an overpayment until the second level of appeal. But you have to file the appeal, and they have different deadlines for that. If you want to stop them from offsetting a post-payment audit at redetermination, you have to file at 30 days instead of 120 days. They’ve shortened that timeframe. 

HME: You say that CMS leaves clues about where audits will go next. What’s an example? 

Fletcher: The OIG work plan comes out every October. This is their roadmap for the coming year. If they say they are going to be looking at oxygen, that tells me I should be doing an internal audit on my oxygen qualifications. There’s no such thing as a random audit. They won’t waste their time and money.



Respectfully, to Denise the timeline for these audits and the challenges they present on Appeal have been orchestrated by CMS as a cash siphon on the Providers.  While CMS can boast it has a challenge venue in place for Providers, it's ALJ's, what it does NOT offer is a Provider's ability to regain the expenses from the challenges of the true Appeal process. 

As reimbursements continue to decrease the recoupment dollars on these challenges on Appeal will become smaller to a Provider compared to the administrative and legal cost for the Appeal not to mention the recoupment cash drain that could begin during this Appeal process.  This entire alternative of the Appeal process has been architect extremely well by CMS but until Providers campaign Congress to grant jurisdiction for civil penalties for deliberate inexcusable wrongs by CMS Contractors within The Federal Courts for successful Appeals all these Appeal challenges could prove 'fruitless" in the longrun.  Providers will get less "Bang" for their "Buck"!  This is for ALL healthcare Providers NOT just HME.

The Nichole Medical case has brought the attention to everyone that CMS Contractors do error and challenging them can be successful but at what costs should be a Provider's guage for any potential Appeal.  The Assistant U.S. Attorney admitted to The Federal Court his Client, The CMS Contractor,  indeed was wrong and caused the insolvency of Nichole Medical.  The resuted Decision from The Nichole Medical case was Federal Courts lack jurisdiction for ANY/ALL claims arising under The Medicare Act.  Jurisdiction under The Act is only at The Medicare ALJ level.  The Medicare ALJ jurisdiction is only for determinatiion of benefits!  Providers have NO venue with jurisdiction for civil complaints! 

This is the Primary Appeal the industry needs to file with Washington!!!