Medicare Compliance & Reimbursement

The pressure is on, so prepare accordingly for possible reviews.

No practice wants to hear that there’s a RAC attack coming its way. But unfortunately these auditors have announced dozens of review issues within the past two months, indicating that they are stepping up their audits of many services common to Medicare providers.

Background: Recovery audit contractors (RACs) review Medicare claims for errors and collect a contingency fee based on the amount they recover. Much like MACs, there are different RAC contractors for the various regions in the country, and each one publishes the open issues that it is in the process of auditing.

Review: Your practice should take note of these audit areas to ensure that you aren’t at risk of scrutiny for these visits, which auditors in Regions two and three (RAC contractor Cotiviti) and Region one (RAC contractor Performant Recovery) are reviewing:

• Global Surgery: Pre- and Postoperative Visits: Overpayments associated with minor and major surgeries are under the microscope, including E/Ms billed during 10-day or 90-day global periods without modifiers, and E/M services billed the day of a minor (0-day) surgery without a modifier.
• Excessive Units of Hospital Services: Both initial hospital care and subsequent hospital care codes “are per diem services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice,” Cotiviti said.
• Hospital Discharge Day Management Service: Medicare only pays one hospital discharge day management service per patient per hospital stay, which is billed by the attending physician of record only.
• Office Visits Billed for Hospital Inpatients: If you see a patient in the inpatient hospital setting, you should use a code from the 99221-99233 or 99238-99239 series, not a code from the 99201-99215 range, because these are reserved for outpatient visits.
• New Patient Visits: “Claims are recouped when a provider bills a new patient visit code and the same provider or a provider from the same group practice and with the same specialty has performed any other E/M services within a three-year period of time,” Performant says.

Do Your Homework

No amount of preparation can alleviate the dread a RAC letter brings — but, remember it’s just a notice. The correspondence should spell out which records to compile, and the deadline by which you should have those records ready to be audited. Know you have rights and respond quickly to avoid hassles.

Respond with evidence: Oftentimes, the letter is a wake-up call to problems that need to be addressed in your practice. Go through the notice, do your research, appeal the claim, and avoid the in-person audit altogether. The more your documentation supports your claim — the less time you will spend in the throes of a RAC audit.

Legal advice: “For a provider facing an audit, responding to the audit findings sometimes will involve a maze of statutes, regulations, manual provisions, and other written guidance,” says Michael D. Bossenbroek, Esq. of Wachler & Associates, P.C. in Royal Oak, Michigan, “Properly understanding these standards may give the provider appropriate technical defenses in the audit.” Remember, legal counsel can help you sift through the paperwork and point you in the right direction with insight and compliance information.

Silver lining: Ultimately, the audit can even have positive effects on your practice. Being audited is no fun, of course, but it can offer a chance to review what you’re doing well and not-so-well now and to fix it going forward. If you end up catching coding or billing errors that result in a repayment, you can set up systems to prevent such errors in the future. Prepare thoroughly and stay calm during the process, and you could end up with a better practice than before.