Medicare Compliance & Reimbursement

Audit not and your claims will be fair game for government entities and whistleblowers trolling for Medicare overpayments. You can, however, cast an effective compliance net with these expert tips for policing your own claims and managing scenarios where you may have billed Medicare improperly.

1. Bulletproof your operations with prepayment reviews. That's the tack that cardiology consultant Jim Collins, CCC, CPC, recommends his clients take. To perform a prospective audit, you place "charges on hold for the audit sample," conduct the audit and correct any inappropriately coded services before submitting the claims, advises Collins, president of CardiologyCoder.com Inc.

Using a prepay approach for all claims can improve your compliance track record to the point that you may be safe just reviewing a sample to detect problems.

For example, many skilled nursing facilities routinely do what's known as the "triple check" where representatives from rehab therapy, nursing, and billing review claims and supporting medical record documentation before billing. Over time, providers who do the triple check "adjust their systems to ensure they are gathering accurate data and documentation to support their claims," says Victor Kintz, MBA, CHC, LNHA, RAC-CT, CCA, managing director of operations for the Polaris Group based in Tampa, Fla. Thus, at some point, the SNF can probably move to doing the check on a certain percentage of claims -- depending on the volume of claims, adds Kintz.

Some consultants argue that doing prospective reviews exclusively avoids unearthing a can of worms that the organization then has to address. There is "a risk to doing retrospective audits -- and  lot to be said for auditing in advance," agrees attorney Robert Markette Jr., CHC, partner, Gilliland & Markette LLP in Indianapolis, Ind. He believes, however, that most providers feel that some retrospective auditing is appropriate to do. As an upside, he notes that he has had clients find on a retrospective audit that they had been underbilling, "and could have been paid for this or that."

The advice about whether to do a retroactive audit may vary depending on whether "there is a chance that someone else will likely uncover improperly received funds," says attorney Richard Blake with Bricker & Eckler in Cleveland, Ohio. "For example, you hear rumblings that 'Dr. Jones' in the practice has been billing improperly in some way. And you hear reports or believe that someone else is looking at that issue." In that case, "it could be in your interest to do a retrospective audit before a whistleblower or the government finds the overpayments."

Atlanta healthcare consultant Darlene Greenhill, whose usual focus is on auditing current claims and educating staff about what to look for, also thinks providers should consider doing retroactive audits if they find red flags. For example, in one case, a CFO told Greenhill he had noted that the organization's skilled nursing facility had a lot of high Resource Utilization Group payment categories. "And he was worried something was amiss."

billing. The major question with retroactive audits is what to do if you find out the organization may have been billing Medicare improperly. The answer depends on the extent of the problem.

Suppose you self-audit a small sample of claims and  find a couple of overpayments involving different issues, says attorney Mark Kopson, with Plunkett Cooney in Bloomfield Hills, Mich. Then you do a larger audit that shows no pattern of problems or intentional billing issues. "Simple repayment can resolve those errors," Kopson says.

"That's a completely different kettle of fish than a scenario where there is a pattern of ongoing -- whether intentional or not -- miscoding and billing."

Protect your investigation: "In general," says Markette, "when someone tells you there's a huge coding/billing problem [resulting in overpayments] ... your first move might be to get outside counsel" on the case.

That way, " your investigation into the matter is privileged. The counsel obtains an outside reimbursement/coding consultant to look at the issue."

Tough call: If the organization believes in good faith after an investigation into the allegations that the auditor is mistaken and it doesn't have a problem -- then what? "In my mind," says Markette, that "discharges your obligation to self-report. If you ignore it, however, the government investigator can later claim that you kept the overpayments based on deliberate indifference or reckless disregard of the truth," he adds.

"The flip side is if you do an investigation that leads you to believe you don't have an obligation to self-report, you'd better be prepared to defend your position."