WHAT
PHYSICIANS SHOULD KNOW ABOUT MEDICARE AUDITS
WHY ARE THERE MEDICARE AUDITS?
Congress and the Executive Branch of the federal
government are publicly committed to eliminate what is considered to be
problematic fraud and abuse in the federal Medicare and Medicaid programs.
Federal statutes and regulations have been enacted, along with substantial
federal funding, to attack this perceived drain on the resources of the
federal government. Although Medicare fraud and abuse is not systemic or
widespread, individual cases can involve significant sums of money.
Investigations by the federal government have identified
not only possible fraud and abuse cases requiring criminal prosecutions,
but also inadvertent errors by physicians in Medicare reimbursement that
do not constitute fraudulent or criminal activity. As a consequence,
federal law has compelled the Department of Health and Human Services to
select various insurance carriers around the country to conduct audits of
physicians seeking reimbursement from Medicare.
WHAT DOES MEDICARE AUDIT?
These insurers conduct audits to identify inappropriate,
medically unnecessary, or excessive services that result in aberrant
billing patterns. Unusual changes in billing patterns often trigger a
Medicare audit. Nationwide data bases compiled by the federal government
are used to detect inappropriate Medicare billing practices. Statistical
samplings are used to conduct the audit.
It is critical for physicians to fully document the
claims being made to Medicare, especially in the area of medical
necessity. Physicians must be completely aware of the latest Medicare
billing regulations and documentation requirements.
HOW DOES THE AUDIT BEGIN?
Often, a physician is first notified of a Medicare audit
upon the receipt of a Preliminary Notice of Audit Results letter. This
letter is typically a thorough review of claims submitted and a demand for
repayment. Auditors may also appear in person to review the physician’s
charts. Since criminal fraud investigations are usually initiated with a
subpoena for records, an audit notice is an indication that a repayment
request is being sought rather than a criminal indictment. Nevertheless, a
physician who receives an audit notice or a visit from an auditor should
consult with an attorney experienced in health care law to determine how
to respond to the audit.
A physician generally has thirty days to respond in
writing to the allegations. Additional time to respond to the audit can be
obtained by the physician.
Auditors are entitled under federal law to examine the
records of a Medicare patient. Consent from the patient is not necessary
because Medicare patients have already provided the necessary
authorizations when they seek to recover Medicare benefits.
There is a six year statute of limitations on Medicare
audits. The statute of limitations is three years if the physician is
"without fault".
Physicians that rely upon specific billing information
and instructions from Medicare may avoid liability for repayment. Thus, it
is important that physicians are not only prepared to provide
documentation of the medically necessity of their services, but also
provide documentation that they followed Medicare rules in submitting
claims.
CAN I APPEAL AN AUDIT DECISION?
Final demand for repayment is often made with the
receipt of a "Final Notice of Audit Results" letter. Physicians
have the right to appeal to the carrier through a desk review, an appeal,
and a Fair Hearing where the physician can obtain access to the evidence
and Medicare guidelines being utilized by the carrier. Physicians can
retain the services of an attorney to defend themselves at Fair Hearings.
A second layer of appeals is possible through a hearing with an
administrative law judge and finally, an appeal hearing with the Social
Security Administration.
However, physicians may be requested to repay the amount
claimed during the appeal process. In fact, federal law allows carriers to
offset future Medicare payments to repay the amount being sought by the
federal government.
Accordingly, physicians facing Medicare audits should
strongly consider calling an attorney experienced in health care law to
represent their interests against the federal government.
