Medicare Compliance & Reimbursement

Rule No. 1 for dealing with the MICs (Medicaid Integrity Contractors): You can't count on them following the standardized rules and safeguards that rein in the RACs. MIC audits are conducted on a state-by-state basis, notes Steve Lokensgard, special counsel with the Minneapolis office of the law firm of Faegre & Benson LLP. And he cautions that unlike the RACs, the MIC program provides no national standards governing:

• How far back the MIC auditors can go;

• How many records the MICs can request from providers to produce in a certain time frame; and

• What the appeal process will be.

Instead, CMS says the standards will be based on state law, Lokensgard notes.

All bets may be off: But don't expect MICs to always follow state requirements, according to a CMS Open Door Forum on the program. "If you're in state X and the state Medicaid agency typically looks back three years," said ODF presenter Barbara Rufo, director of the Medicaid Integrity Contracting Division, "then we typically would look back three years. That's subject to change and if there's ... reason to extend that or ... to reduce that look back period, then that's certainly very possible."

Rule No. 2: Know the function of the three MIC contractors, and what an audit portends. In short, the MICs include three types of contractors: review, audit, and education. "The review contractors will do data mining to find issues indicative of an erroneous claim," explains Lokensgard. The audit contractors will then conduct the audits either onsite or as a desk audit, according to Rufo. Education MICs will pick up on concerns uncovered by the other two MICs to educate providers and others about Medicaid payment integrity and quality of care, according to CMS.

In other words, "providers aren't going to be audited at random by MICs," says attorney Paula Sanders, a partner with Post & Schell in Harrisburg, Pa. "The review MICs will have already found something aberrant that suggests to them that the provider did something wrong," she says. And "the MICs will check with state and federal entities like the Medicaid Fraud Control Units and the HHS Office of Inspector General to make sure the provider isn't already under investigation before they start their audit."

Rule No. 3: Steep your organization in the state's Medicaid billing and documentation requirements. Doing so can put you more on par with the MICs, which will be doing the same. "In order for MICs to be effective, they have tolearn and understand the intricacies of every Medicaid program," says Sanders.