Tag: Audit

WASHINGTON – The HHS-OIG’s Fall 2023 Semiannual Report to Congress highlights more than $3.44 billion in expected recoveries resulting from audits and investigations conducted during fiscal year 2023.  In FY 2023, HHS-OIG reported 707 criminal enforcement actions against individuals and entities suspected of engaging in crimes targeting HHS programs and the people they serve. They also reported 746 civil actions, which include false claims and unjust-enrichment lawsuits filed...

YARMOUTH, Maine – The end of Medicare’s competitive bidding program for knee and back braces on Dec. 31 could open the door to increased audit activity for orthotics in 2024, industry consultants predict.  “We’ve already seen the Supplemental Medical Review Contractor (SMRC) add braces back onto their project list and the Recovery Audit Contractor (RAC) still has them on their approved list,” said Kelly Grahovac, general manager of the van Halem Group. “But...

WATERLOO, Iowa – With the public health emergency officially over, HME providers need to prepare for a return to “normal” – including a return to audits, say industry stakeholders.  On April 28, ahead of the PHE ending on May 11, CMS published directions for claims impacted by the COVID-19 pandemic. Among the agency’s guidance: Continue to use the CR modifier for rentals and supplies, and return to proof of delivery with a patient’s signature.  “During...

WASHINGTON – President Joe Biden has announced that the public health emergency will end on May 11, 2023.  Under the last declaration in January, the PHE was set to end on April 11.  “The advance notice goes beyond HHS Secretary Xavier Becerra’s previous guidance to health care stakeholders that the agency would provide at least 60 days advance notice before ending the PHE,” AAHomecare noted in a bulletin.  Knowing when the PHE will end gives industry...

YARMOUTH, Maine – After lying largely dormant during the public health emergency, audits are on the rise, including for respiratory claims, say industry consultants.  While audits never stopped completely during the PHE, waivers of certain coverage criteria, including for oxygen equipment and CGMs, helped lessen the burden on providers. But UPIC auditors are now increasingly targeting claims covered by those waivers, says Kelly Grahovac.   “It’s almost like they...

LIVERMORE, Calif. - Performant Healthcare Solutions has announced that CMS has awarded the company the Medicare Secondary Payer (MSP) Recovery Audit contract, also known as the Commercial Repayment Center (CRC), for a six-year term consisting of one base year and five option years. This is a contingency fee contract, meaning CMS pays Performant a percentage of overpayment recoveries returned to the Medicare Trust Fund. “This contract win is an affirmation of our demonstrated history of continuous...

WASHINGTON – CMS plans to primarily focus MAC, RAC and SMRC medical reviews on claims with dates of service outside of the public health emergency, the agency stated in a recent clarification.  CMS stated:  “During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once...

WASHINGTON – CMS plans to primarily focus MAC, RAC and SMRC medical reviews on claims with dates of service outside of the public health emergency, the agency stated in a recent clarification.  CMS stated:  “During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once...

ATLANTA – The government has gotten much better at analyzing data for evidence of fraud, so HME providers need to be sure they are maintaining a culture of compliance.  That was a main takeaway during “Understanding How the Government Uses Audits to Bring Fraud Investigations” at Medtrade on Monday.  “(The Center for Program Integrity) is currently tracking all claims,” said Josh Skora, a partner with the law firm K&L Gates. “Once they have aberrant...

ATLANTA - As the HME industry ventures further into a post-pandemic landscape, providers should move away from reliance on audit waivers and flexibilities, Medtrade East speakers say.  While audits never stopped completely during the throes of COVID-19, federally sanctioned waivers helped staunch the burden to providers while the pandemic raged. Yet, now with the viral threat easing up, so are the audit breaks.  “I strongly encourage any suppliers who are relying on waivers...