Have you had a Medicare audit? Medicare has a number of program integrity contractors that can pry into your records, while you are sleeping, as well as during the day for an onsite “surprise ” visit. Most likely if you have had a Medicare audit, it was most likely a medical review of a claim by either your Medicare Administrative Contractor, or the regional Recovery Auditor (RAC). Medicare audits, specifically the RAC audits were under scrutiny this week at the Senate Special Committee on Aging hearings “Improving Audits: How We Can Strengthen the Medicare Program for Future Generations“. The esteemed members of this Senate Committee got an earful, mostly not favorable, about the RAC program in particular, but Medicare audits in general.
Medicare Audits: First Coast Insights
First Coast Service Options, the long time MAC for Florida provided testimony that game some interesting insight into how the MACs go about the audit process.
Specifically as it relates to audit activities, which is the subject of this roundtable, we conduct pre-pay and post payment Medical Review. Our Medical Review framework is data driven and uses multiple data sources, such as our own claims-based data warehouse, Comprehensive Error Rate Testing Results, and national data sources such as the Part B analytics system and the Chronic Conditions Warehouse coupled with staff that includes both statisticians and clinicians so that we can determine where there are program vulnerabilities and undertake the appropriate actions to successfully address these. The analysis of data can lead to the identification of service-wide anomalies at the procedure code level or provider specific reviews. Whenever possible we begin by determining what can be done through provider education and then we move through the Progressive Corrective Action (PCA) process as needed. The PCA process is designed to align the identified risk to the program with the corrective action to ensure it is proportional and consistent with the Medical Review guidelines we follow where we reimburse legitimate providers for reasonable and necessary services that are coded correctly, use the least intensive intervention possible, move providers on and off review quickly and do reviews on a pre-pay basis whenever possible.
This gives some insight into not only the resources that are available to the various Medicare program integrity contractors, but also insight into how sophisticated data analysis and data mining have become. By understanding the various ways in which providers are profiled and selected, you will have insight into the variants that may generate a knock at the door or a request for a probe. Providers must be adept at profiling their own data to assess risk.
If you are in charge of audits at your facility, I recommend reviewing the remarks of those that testified. It is worth your time: Those providing testimony at the hearing included:
- Diana Haramboure, Senior Vice President and Chief Administrative Officer, First Coast Service Options
- Margaret Hambleton, Vice President and Corporate Compliance Officer, Dignity Health
- Kathleen King, Director, Healthcare Government Accountability Office
- Chad Janak, Vice President, Audit Operations, Connolly Healthcare
- Mindy Hatton, Senior Vice President and General Counsel, American Hospital Association
Have you been under a Medicare audit or RAC audit? Do you have an internal quality review and audit program to review your documentation, coding and billing? Do you assess risk and prioritize what and how to audit?