Medicare Compliance & Reimbursement

You'll draw CMS's attention if you fail to respond to Comprehensive Error Rate Testing (CERT) medical review requests. CMS staff will be making calls to providers that haven't responded to CERT requests for medical review, MACs Cahaba GBA, Noridian, Highmark, and Palmetto GBA say on their Web sites.

"Although you may have already received letters and telephone calls from the CERT contractor, these additional efforts by CMS to obtain adequate documentation may change your claim's status from 'improper payment' to 'proper payment,'" they say. "This will allow us to calculate a more accurate Medicare FFS error rate, while also reducing the amount of improper payments."

You might keep an eye on New York, which has developed a reputation for having one of the tougher Medicaid compliance enforcement efforts. The New York Association of Homes & Services for the Aging members are seeing "very aggressive tactics by Medicaid auditors," says Dan Heim, president and CEO of the nonprofit trade group representing long-term care providers. "The investigations involve situations where an entire claim is deemed to be abusive and subject to  recoupment for relatively minor paperwork errors or other issues (such as delays in getting doctors' signatures on documents) -- even though the underlying services were medically necessary and validly rendered.

"This isn't occurring just in long-term care, but also in acute care, primary care, pharmacy and behavioral health," Heim tells Eli.

Fighting back: "Coalitions of providers have emerged to promote legislation that seeks to curb some of the practices the OMIG uses for its investigations and the basis on which claims are being denied," Heim reports.

The legislation, which was sponsored by both the state Senate and Assembly, didn't pass in 2010. But the bill did generate a lot of discussion during hearings held by the legislature, Heim reports. "We are ... making some modifications to the legislation and seeking to reinforce what we think was the original intent of the legislation that created the OMIG -- namely to focus on true fraud and abuse in the Medicaid program. If estimates of the level of fraud in the system are accurate, the OMIG could increase its recoveries by focusing on those areas," Heim says.

"We are cautiously optimistic that we will get provisions enacted into law this year that will refocus the OMIG's efforts on combating true fraud and abuse rather than trying to recover dollars from providers that have furnished services and may have made some small error or oversight in paperwork."