Audits: Too much of a bad thing

YARMOUTH, Maine - Some home medical equipment providers are learning that any relief they get from being released from a prepay review can be short-lived.

Industry stakeholders report that some providers released from a prepay review are being put back on a prepay review as little as a few months later.

“It used to be that I would tell providers, 'Once you get through this, you'll be in good shape and you'll have the green light,'” said Kelly Wolfe, CEO of Regency Billing and Consulting. “Not anymore.”

Another scenario, according to stakeholders: Providers released from a prepay review are getting hit with a post-pay review even before the results of the prepay review are known.

Stakeholders have a few theories as to what's going on. The most common: That the spike in billing that often occurs after a provider is released from a prepay review raises red flags again.

“Your inclination is to blast out everything that has been stockpiling for the past three months or six months,” said Sylvia Toscano, owner of Professional Medical Administrators. “But you have to send in the claims incrementally.”

Other theories: That the contractors are targeting a certain doctor and, therefore, any provider he's referring to is getting audited repeatedly; or that investigators working for the same contractor aren't talking to each other about previous audits, resulting in recycled cases.

“We've found that the investigators aren't always aware, which is kind of scary,” said Wayne van Halem, president of The van Halem Group. “In one case, we were able to inform an investigator of a previous audit and they cancelled the new audit.”

Sometimes, it's as simple as this, stakeholders say: Contractors want to check up on providers.

“They want to know, 'Are you still doing a good job now that we've let you off the hook,'” said Andrea Stark, a reimbursement consultant with MiraVista. “They reserve the right to come back in.”

Contractors may have the right to come back in, but that's of little comfort for providers trying to negotiate back-to-back prepay reviews.

“Many of these providers are still trying to get back on their feet after surviving the first one,” van Halem said.